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The use of digital technologies in managing bowel conditions has been a topic of interest among healthcare practitioners. The objectives of this paper were to provide information about the types of digital technologies that have been used for bowel management and the context of the studies; identify the gaps and challenges in digital technologies for bowel management and propose new methods and techniques for the application of digital technologies in bowel management. A scoping review was conducted following the principles of Preferred Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). A search was conducted on six academic databases. 1891 papers were retrieved from the initial search; however, 6 papers were included based on the inclusion and exclusion criteria. The findings suggest that published work focused mainly on a research context and with a narrow focus targeting sub-categories of bowel conditions and not implemented in the context of everyday use. The findings also illustrate the variety of early-stage developments focused on increasing support for severe bowel dysfunction, for example, through biofeedback to aid muscle control training, or the placement of artificial anal sphincters to increase rectal perception. However, technology to support bowel management for broader populations with less severe or variable symptoms appears limited. Future work would be to conduct empirical research in the application of advanced technologies such as on-organ sensors in managing bowel conditions. [ABSTRACT FROM AUTHOR]

This study aims to evaluate the quality and reliability of YouTube videos about bowel management in children. On April 6th, 2023, the search results for "bowel management in children" on YouTube were rated independently by two authors. JAMA Benchmark Criteria (score 0–4) and a modified DISCERN tool (score 16–80) used for quality and reliability assessment. Data was analyzed by Chi-square test and one-way analysis of variance (ANOVA). Out of 48 videos included, 15 (31.2%) videos were intended for professionals and 33 (68.8%) for the public. The mean number of views was 144.806 and duration was 22 ± 28.4 min. The respective mean duration of videos for professionals 57.7 ± 21.4 min and median number of views was 404.5 (17–8.840) and those for public was 5.7 ± 10.7 min and 8400 (8–5.175.975) (both, p < 0.005). The respective mean DISCERN and JAMA scores of the videos for the public was 45.30 ± 13.18 and 2.93 ± 1.07, and for professionals 75.73 ± 6.52 and 3.8 ± 1.06 (both, p < 0.05). Although the reliability of the videos uploaded for the professionals about pediatric bowel management was higher than for public, duration of the videos was longer and the viewing rates were lower. Shorter but comprehensive and easy-to-understand guidance videos for the public may be of help. Descriptive study. IV. • Due to the widespread use of technology, many patients refer to the internet as an initial stage to access the health information or during the course of their treatment. • Bowel management is used by patients with bowel disabilities to manage fecal incontinence or constipation. • It is more difficult to obtain accurate and quality information from social media on topics where awareness is relatively limited and less popular with the general public. • This study aims to evaluate the quality, reliability and adequacy of the videos presented on YouTube on bowel management program. • YouTube videos about bowel management in children are at a quality level that can be improved. • Shorter but comprehensive and easy-to-understand guidance videos for the public are needed. [ABSTRACT FROM AUTHOR]

Malone antegrade continence enemas (MACE) provide a conduit in which the patient can achieve improved continence, be clean of stool, and gain independence in maintaining bowel function. The Mini-ACE® is a low-profile balloon button that is used to facilitate the administration of antegrade enemas. We sought to describe our practice and short-term outcomes. This work is a retrospective review of the Mini-ACE® appendicostomy button from April 2019 to March 2021, with follow-up concluding in October 2021. Patient demographics, colorectal diagnoses, and outcomes were examined. Forty-three patients underwent Mini-ACE® placement; 22 (51%) were male. The average age at Mini-ACE® insertion was 9.2 years (range 3–20 years). The most common diagnoses were functional constipation in 19 (44%), anorectal malformation in 15 (35%), and Hirschsprung disease in 3 (7%), spinal differences 3 (7%). There were no intra-operative complications, but 5 (12%) required prolapse resection. The median length of stay was two days (IQR 1, 4). Patients achieved self-catheterization at 4.5 [3,7] months from MACE creation, with 38 children (88%) reporting excellent success in remaining clean of stool. The Mini-ACE® appears to be a safe and low-profile option for antegrade continence enema access. Further research is needed directly comparing complications and patient satisfaction rates between different MACE devices and overall quality of life. Level IV. [ABSTRACT FROM AUTHOR]

Recent studies in children with idiopathic rectal prolapse report up to 48% require surgical intervention to manage refractory disease. We sought to examine outcomes of our non-surgical approach to managing rectal prolapse using a bowel management program. A retrospective review was performed for all children with the diagnosis of rectal prolapse between 2011 and 2020. Children with a rectal polyp or hemorrhoid were excluded. 47 children with rectal prolapse were identified (median age at diagnosis of 4 years (IQR 3,7.75); age ≤ 4 years n = 30; age > 4 years n = 17). Associated diagnoses included constipation (n = 45, 96%) and psychiatric diagnoses (n = 7, 14%). Children underwent a bowel management program including stimulant laxatives in 44 (94%) and osmotic laxatives in 2 (4%). Median follow-up time was 181 days (IQR 77, 238). Median time to resolution of rectal prolapse was 9 months (IQR 4, 13) with a maximum time to resolution of 31 months. We compared children ≤ 4 years old (Group A) to those > 4 years old (Group B). Psychiatric diagnoses were less common in Group A (3.5 vs. 38.9%, p = 0.003). Median time to spontaneous resolution was 6.5 months (IQR 3.5, 9.5) in Group A versus 13.5 (IQR 4, 16) months in Group B, p = 0.13. No differences in surgical intervention were identified. Three (6.4%) patients required surgery for prolapse. A bowel management program is an effective treatment for most children with rectal prolapse. This data suggests that surgical intervention is unnecessary in most children. III. [ABSTRACT FROM AUTHOR]

Children with severe constipation and a neurodiverse disorder (Autism and/or developmental delay) represent a challenging bowel management group. Treatment outcomes with laxative or enema therapy remain limited and are often complicated by patient/caregiver compliance. We hypothesized that children with neurodiverse disorders and severe constipation would benefit from a bowel management program (BMP) that includes early use of antegrade enemas. Children requiring BMP in the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC) registry with diagnosis of constipation and/or constipation with pseudo-incontinence were reviewed. Those with Hirschsprung disease and/or Anorectal Malformation were excluded. BMP needs in patients with a neurodiverse diagnosis were compared to those without to evaluate differences in BMP's. 372 patients requiring a BMP were identified. 95 patients (58 autism spectrum, 54 developmental delay) were neurodiverse, and 277 patients were not. Neurodiverse patients had a higher prevalence of enema therapy 62.1% (59/95) vs. 54.9% (152/273) and use of antegrade enema therapy 33.7% (32/95) vs. 21.2% (58/273), p = 0.126. Neurodiverse patients were older 37.9% (36/95) > 12 years vs. 23.1% (63/273), p = 0.001 and 47.6% (10/21) were changed from laxative to enema therapy over time. 80% (8/10) of those changed from laxatives to enemas used antegrade therapy. 67.3% (35/52) of neurodiverse patients followed over time were on enema therapy at the most recent visit with 80% (28/35) requiring antegrade therapy. A large portion of patients with a neurodiverse disorder who fail laxative therapy use antegrade enemas to achieve effective bowel management. Early consideration of an antegrade conduit may simplify treatment in this group of children. III. [ABSTRACT FROM AUTHOR]

To systematically determine whether use of the spinal cord stimulation (SCS) system to restore cough may improve bowel management (BM) in individuals with spinal cord injury (SCI). Experimental studies (clinical trial). Inpatient hospital setting for electrode insertion; outpatient setting for measurement of respiratory pressures; home setting for application of SCS. Participants (N=5) with cervical SCI. A fully implantable SCS cough system was surgically placed in each subject. SCS was applied at home, 2-3 times/d, on a chronic basis, every time bowel regimen was performed and as needed for secretion management. Stimulus parameters were set at values resulting in near maximum airway pressure generation, which was used as an index of expiratory muscle strength. Participants also used SCS during their bowel routine. Airway pressure generation achieved with SCS. Weekly completion of Bowel Routine Log including BM time, mechanical measures, and medications used. Mean pressure during spontaneous efforts was 30±8 cmH 2 O. After a period of reconditioning, SCS resulted in pressure of 146±21 cmH 2 O. The time required for BM routines was reduced from 118±34 minutes to 18±2 minutes (P <.05) and was directly related to the magnitude of pressure development during SCS. Mechanical methods for BM were completely eliminated in 4 patients. No patients experienced fecal incontinence as result of SCS. Each participant also reported marked overall improvement associated with BM. Our results of this pilot study suggest that SCS to restore cough may be a useful method to improve BM and life quality for both patients with SCI and their caregivers. Our results indicate that the improvement in BM is secondary to restoration of intra-abdominal pressure development. [ABSTRACT FROM AUTHOR]

Enemas have become a common practice for treating fecal incontinence and severe constipation. Several patients receiving enemas complained of severe, colicky, abdominal pain during enema administration and complained that the duration for fluid to pass was progressively increasing. Contrast studies showed a startling picture of severe right colon dilatation and a spastic, narrow, left colon. An investigation was started to seek the origin and possible management of this condition. Medical and radiologic records were reviewed retrospectively, with emphasis on the type and ingredients of enemas used, the duration the patients had been receiving enemas, and their original diagnosis. A literature review was done on previous reports of this condition and publications related to long-term use of enemas. This series included 22 patients (average age, 19.6 years; range, 8–54) with fecal incontinence due to anorectal malformations (10 cases), myelomeningocele (5), cloaca (2), severe colonic dysmotility (2), Hirschsprung's disease (2), and sacrococcygeal teratoma (1). The average duration of enema use was 13.7 years (range, 4–45). The composition of the enemas included saline/glycerin (six cases), only saline solution (five), saline/glycerin/soap (four), plain water (three), and one case each of molasses/milk, saline/glycerin/soap/phosphate, saline/phosphate, and only phosphate. The enemas were performed in an antegrade fashion in 21 cases and rectally in 1. All patients had a dilated right colon and a narrow, spastic, left, transverse, and descending colon. Four patients underwent colonoscopy, colonic manometry, and mucosal biopsies, which did not help in explaining the etiology of the problem. In the literature, 43 reports mentioned a "long-term follow-up" for the administration of enemas, but we could not find a description of symptoms, such as in our cases. An intriguing and, to our knowledge, previously unreported complication of chronic enema use is presented. We call attention to an overly concerning complication and report our findings in the hope that they will aid and stimulate more investigations into this condition. Several hypotheses to explain the cause are presented, as well as potential treatment options. [ABSTRACT FROM AUTHOR]

We sought to examine the long-term clinical success rates of a bowel management program (BMP) for children with severe constipation or fecal incontinence. A single center review was conducted of children (≤ 18 years) enrolled in a BMP and followed in a colorectal specialty clinic (2011–2017). All patients who completed an initial week of the BMP were included. Patients enrolled in a BMP after 2018 were excluded. Success was defined as no accidents and < 2 stool smears per week. A total of 285 patients were reviewed. BMP was initiated at a median age of 7 years (9 months-17 years). Primary diagnoses included functional constipation (112), anorectal malformation (ARM) (104), Hirschsprung Disease (HD) (41), rectal prolapse (14), spina bifida (6), fecal incontinence (3) and other (5; 4 sacral coccygeal teratomas and a GSW to the buttocks). Initial bowel regimen included large volume enema in 54% and high dose stimulant laxative in 46%. The initial Bowel Management Week (BMW) was successful in 233 (87% of adherent patients) patients with 17 (6%) non-adherent. One hundred twenty-two patients had follow-up at 12 months (72% success amongst adherent patients, 7% of patient non-adherent) and 98 patients had follow-up at 24 months (78% success amongst adherent patients, 10% of patients non-adherent). 21/154 (14%) patients started on enemas were later successfully transitioned to laxatives and 13/132 (10%) patients started on laxatives subsequently required enemas in order to stay clean. Clinic phone contact occurred outside of scheduled visits for adjustment to the BMP in 44% of patients. 33% of patients had surgery to aid bowel management (antegrade colonic enema (ACE) = 81, resection + ACE = 13, diverting stoma = 4). Median follow up was 2.5 years (5 weeks–7 years). Children who follow a structured BMP with readily available personnel to provide outpatient assistance can experience successful treatment of severe constipation or fecal incontinence long-term. A multi-institutional collaboration is necessary to identify factors which predict failure of a BMP and non-adherence. Single-center retrospective chart review. 3 [ABSTRACT FROM AUTHOR]

The aim of the study was to assess the impact of bowel management on the quality of life in children with spina bifida with overactive bladder and detrusor sphincter dyssynergia. The research was carried out over the 2014–2017 period, during which 70 patients with spina bifida with overactive bladder and detrusor sphincter dyssynergia were observed. The first group (group 1) consisted of 35 patients who were administered bowel management combined with anticholinergic medication therapy and CIC. The second group (group 2) consisted of 35 patients who were treated only with anticholinergic medication therapy and CIC. Bowel management included daily enema, laxative application, and a special diet, with a view of treating constipation and fecal incontinence that was estimated on the basis of Roma III criteria, the echosonographically determined transversal rectal diameter, and encopresis frequency. The effects of the administered bowel management on urinary incontinence were estimated on the basis of the average dry interval between two CICs. Regarding the quality of life, a KINDL questionnaire was used for children and parents to determine the overall quality of life, but also the various aspects of the quality of children's life (physical well-being, emotional well-being, self-confidence, family, friends, school, disease). The test score ranges from 0 to 100, where 0 is the lowest and 100 denotes the highest quality of life. The follow-up period of every patient was one year. At baseline, there was no significant difference between the groups regarding demographic and clinical features (p > 0.05). After one year, treatment by bowel management demonstrated significant improvement for both fecal constipation/incontinence and urinary incontinence (p < 0.001). The bowel management group showed improved overall quality of life in contrast to the group without bowel management 88.9 ± 7.1 vs. 55.4 ± 11.4 (p < 0.001, assessed by parents) and 84.5 ± 8.9 vs. 53.4 ± 12.5 (p < 0.001, assessed by children), respectively. Moreover, the positive impact of bowel management on quality of life was confirmed for all domains of the quality of life (physical well-being, emotional well-being, self-confidence, family, friends, school, disease), (p < 0.001 for all), both by the parents' and the children's assessment. Administering bowel management considerably alleviates the symptoms of fecal and urinary incontinence and considerably improves the quality of life. Bowel management should be considered as an integral part of treatment of children with spina bifida. Summary Fig. Image 1 [ABSTRACT FROM AUTHOR]

When born with spina bifida, there are numerous neurologic disorders that accompany this birth defect, including neurogenic bowel. Proactive, systematic, and rational approaches can lead to continence and a more functional lifestyle [1]. Based on the evidence in the literature and expert experience, our approach to bowel management was developed as a step by step, individualized approach. This was converted to a decision tree for easy guidance of treatment decisions. The approach includes teaching patients and families normal bowel function, changes resulting from neurogenic bowel, common pitfalls in bowel management, and techniques that may improve outcomes. The decision tree, starting with dietary management, breaks into a two-fold attack, oral and rectal. Our data as part of the National Spina Bifida Patient Registry (NSBPR) database was compared to public data from the NSBPR. Preliminary data from the NSBPR in 2011 reported bowel continence in 42.1% (n = 898) compared to our clinical outcomes of 72.1% (n = 43). As the variable of bowel continence was further defined and more patients were enrolled, the clinic results were comparable to the national reports. Consistency among providers and caregivers is critical to evaluating the management of continence in spina bifida. While this protocol warrants further evaluation, it is offered as an evidence-based, step by step, approach to bowel management in spina bifida with good outcomes for patient management. [ABSTRACT FROM AUTHOR]

Abstract Purpose Children failing medical management for severe constipation and/or fecal incontinence may undergo surgical intervention for antegrade enema administration. We present a modification of the laparoscopic-assisted percutaneous endoscopic cecostomy (LAPEC) procedure that allows primary placement of a skin-level device. Methods A single-institution retrospective review was performed from 2009 to 2015. In the modified technique the colonoscope is advanced to the cecum, cecal suspension sutures are placed under laparoscopic visualization, and percutaneous needle puncture of the cecum is performed under direct laparoscopic and endoscopic visualization. A skin-level cecostomy tube is then placed over a guide wire. Patient characteristics and 30-day results were analyzed by Fisher's exact test. Results Fifty-two patients underwent attempted LAPEC. Successful LAPEC using both laparoscopic and endoscopic guidance was achieved in 46 (88.5%). A MIC-KEY device was placed in 38. Corflo PEG tube placement was necessary in 14 due to high BMI (mean 28.4). Colonoscopy failed to reach the cecum in 6 and laparoscopy alone was utilized to achieve successful tube placement. Cecostomy site infections occurred in 3 (5.8%), only in those undergoing PEG placement using a pull technique (p < 0.05). Conclusion Primary placement of a skin-level device was successful in the majority of patients undergoing cecostomy tube placement for bowel management utilizing antegrade colonic enemas. This technique avoids a second anesthesia for tube conversion. Visualization via colonoscopy with the use of cecal suspension sutures is recommended. High BMI necessitates initial placement of a PEG tube and complications exclusively occurred in this group. Type of Study Clinical. Level of Evidence IV Case series study. [ABSTRACT FROM AUTHOR]

Abstract Background Appendicostomy and cecostomy are two approaches for antegrade enema access for children with severe constipation or fecal incontinence as adjuncts to a mechanical bowel management program. Each technique is associated with a unique set of complications. The purpose of our study was to report the rates of various complications associated with antegrade enema access techniques to help guide which option a clinician offers to their patients. Methods We reviewed all patients in our Center who received an appendicostomy or cecostomy from 2014 to 2017 who were participants in our bowel management program. Results 204 patients underwent an antegrade access procedure (150 appendicostomies and 54 cecostomies). Skin-level leakage (3% vs. 22%) and wound infections (7% vs. 28%) occurred less frequently in patients with appendicostomy compared to cecostomy. Nineteen (13%) appendicostomies required revision for stenosis, 4 (3%) for mucosal prolapse, and 1 (1%) for leakage. The rates of stenosis (33 vs. 12%) and wound infection (13 vs. 6%) were higher in patients who received a neoappendicostomy compared to an in situ appendicostomy. Intervention was needed in 19 (35%) cecostomy patients, 15 (28%) for an inability to flush or a dislodged tube, and 5 for major complications including intraperitoneal spillage in 4 (7%) and 1 (2%) for a tube misplaced in the ileum, all occurring in patients with a percutaneously placed cecostomy. One appendicostomy (1%) patient required laparoscopic revision after the appendicostomy detached from the skin. Conclusion Patients had a lower rate of minor and major complications after appendicostomy compared to cecostomy. The unique complication profile of each technique should be considered for patients needing these procedures as an adjunct to their care for constipation or fecal incontinence. Type of study Retrospective comparative study. Level of evidence Level III. [ABSTRACT FROM AUTHOR]

Purpose A protocol to treat idiopathic constipation is presented. Methods A contrast enema is performed in every patient and, when indicated, patients are initially submitted to a “clean out” protocol. All patients are started on a Senna-based laxative. The initial dosage is empirically determined and adjusted daily, during a one week period, based on history and abdominal radiographs, until the amount of Senna that empties the colon is reached. The management is considered successful when patients empty their colon daily and stop soiling. If the laxatives dose provokes abdominal cramping, distension, and vomiting, without producing bowel movements, patients are considered nonmanageable. Results From 2005 to 2012, 215 patients were treated. 121 (56%) were males. The average age was 8.2 years (range: 1–20). 160 patients (74%) presented encopresis. 67 patients (32%) needed a clean out. After one week, 181 patients (84%) achieved successful management, with an average Senna dose of 67 mg (range: 5–175 mg). In 34 patients (16%) the treatment was unsuccessful: 19 were nonmanageable, 3 noncompliant, and 12 continued soiling. At a later follow-up (median: 329 days) the success rate for 174 patients was 81%. Conclusion We designed a successful protocol to manage idiopathic constipation. The key points are clean out before starting laxatives, individual adjustments of laxative, and radiological monitoring of colonic emptying. Treatment study Level IV. [ABSTRACT FROM AUTHOR]

Background/Purpose Fecal incontinence is a prevalent pediatric condition with psychosocial impacts on both children and their caregivers. We sought to develop and validate the Cincinnati Fecal Incontinence Scale (CINCY-FIS) as a psychometrically valid measure to assess the quality of life and caregiver impacts of pediatric fecal incontinence. Methods Items were generated through review of previous measures, expert consensus, and pilot testing with feedback from 8 families. Initial study measures were completed by 222 caregivers. Following item reduction, 18 items were subjected to confirmatory factor analysis. Convergent and criterion validity were assessed using correlation. Reliability was established using internal consistency statistics and test–retest reliability at baseline and 2-week follow-up. Results A five factor first-order structure with two higher-order factors demonstrated acceptable fit to the data, was consistent with a priori hypotheses, and was more parsimonious than the alternative model. Convergent validity and criterion-related validity were established for all of the CINCY-FIS scales. Reliability was high and consistent across both measurement occasions. Conclusions The CINCY-FIS is a reliable and valid assessment of pediatric fecal incontinence-specific quality of life and parenting stress. The score is highly sensitive to patient changes making it suitable for both clinical and research purposes. Type of Study Prospective observational. Level of Evidence Study of Diagnostic Test Level II. [ABSTRACT FROM AUTHOR]

Background Chronic constipation is a common problem in children. The cause of constipation is often idiopathic, when no anatomic or physiologic etiology can be identified. In severe cases, low dose laxatives, stool softeners and small volume enemas are ineffective. The purpose of this study was to assess the effectiveness of a structured bowel management program in these children. Methods We retrospectively reviewed children with chronic constipation without a history of anorectal malformation, Hirschsprung's disease or other anatomical lesions seen in our pediatric colorectal center. Our bowel management program consists of an intensive week where treatment is assessed and tailored based on clinical response and daily radiographs. Once a successful treatment plan is established, children are followed longitudinally. The number of patients requiring hospital admission during the year prior to and year after initiation of bowel management was compared using Fisher's exact test. Results Forty-four children with refractory constipation have been followed in our colorectal center for greater than a year. Fifty percent had at least one hospitalization the year prior to treatment for obstructive symptoms. Children were treated with either high-dose laxatives starting at 2 mg/kg of senna or enemas starting at 20 ml/kg of normal saline. Treatment regimens were adjusted based on response to therapy. The admission rate one-year after enrollment was 9% including both adherent and nonadherent patients. This represents an 82% reduction in hospital admissions (p < 0.001). Conclusions Implementation of a structured bowel management program similar to that used for children with anorectal malformations, is effective and reduces hospital admissions in children with severe chronic constipation. [ABSTRACT FROM AUTHOR]

Objective: To develop a reliable and valid scoring tool, the Pediatric Bowel Management Scoring Tool (PBMST), to better guide management of constipation in pediatric patients.Study Design: The project comprised 2 stages, development of the questionnaire and construction of the bowel management score. Two questionnaires were created, one for children aged 8-18 years to self-report and one parent proxy-report for children aged 4-8 years. Questions regarding physical symptoms (n = 6), emotional aspects (n = 2), social activities/school (n = 1), and treatment (n = 1) were included. Patients (or parents of patients) with symptoms of constipation completed the questionnaire. The reproducibility of each question was computed using the Cohen weighted kappa coefficient (κ). A bowel management score was developed using logistic regression analysis, assessing the associations between the questions and impact on self-reported quality of life (QoL). Questions with adequate reproducibility and significantly associated with QoL were incorporated into the score.Results: The questionnaire was completed by 385 patients. Six questions met the inclusion criteria and were incorporated into the score: stool shape (range, 0-3 points), anorectal pain (0-4 points), abdominal pain (0-3 points), frequency of fecal incontinence (0-3 points), assistance of caregivers (0-3 points), and interference with social activities (0-6 points). Differences in bowel management scores among patients reporting no, little, some, or major impact on QoL were statistically significant (P < .001).Conclusions: The newly developed and validated PBMST is a reliable tool for evaluating bowel management strategies in children with constipation. [ABSTRACT FROM AUTHOR]

After operative intervention for Hirschsprung disease (HD) a child should thrive, be fecally continent, and avoid recurrent episodes of abdominal distention and enterocolitis. This is unfortunately not the case for a significant number of patients who struggle following their pull-through procedure. Many clinicians are puzzled by these outcomes as they can occur in patients who they believe have had a technically satisfactory described operation. This review presents an organized approach to the evaluation and treatment of the post HD pull-through patient who is not doing well. Patients with HD who have problems after their initial operation can have: (1) fecal incontinence, (2) obstructive symptoms, and (3) recurrent episodes of enterocolitis (a more severe subset of obstructive symptoms). After employing a systematic diagnostic approach, successful treatments can be implemented in almost every case. Patients may need medical management (behavioral interventions, dietary changes, laxatives, or mechanical emptying of the colon), a reoperation when a specific anatomic or pathologic cause is identified, or botulinum toxin when non-relaxing sphincters are the cause of the obstructive symptoms or recurrent enterocolitis. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: Megarectosigmoid (MRS) is commonly seen in children with anorectal malformations (ARM) and contributes to the high incidence of constipation. Surgical resection has been advocated by some, whereas others propose intense bowel management as the treatment of choice. The aim of this study was to evaluate outcome of both bowel function and configuration after surgical or conservative treatment of MRS in ARM patients. Materials and methods: The study included 79 patients with ARM, excluding perineal fistula, (48 boys, 31 girls) from 1986 to 2007. MRS was diagnosed at colostomy formation or contrast enema performed in the neonatal period. Early in the period, the majority of the patients were treated surgically, whereas in the late 1990s, a conservative approach with intensified bowel treatment was implemented. Contrast enema and bowel function investigations were performed repeatedly during follow-up. Results: MRS, according to radiological criteria, was diagnosed in 26/79 (33%) of the ARM children. Bowel functional outcome was similar regardless of surgical or conservative treatment and comparable to function in ARM children with non-MRS. The radiological signs of rectal dilatation and elongation disappeared after surgical intervention, but normalisation of the rectosigmoidal configuration was also seen with age in the conservative group. Conclusions: Bowel functional outcome in ARM children with MRS was similar after either surgical or conservative treatment during follow-up. The radiological signs of rectal dilatation and elongation disappeared also in the conservatively treated patients over time. [Copyright &y& Elsevier]

Abstract: Aims: Transanal colonic irrigation has been shown to be effective in bowel management program in adults. However, there exist limited data in children. We appraised the effectiveness of this technique in a series of children with incontinence or constipation and overflow soiling. Methods: Following ethical approval, a review of children with incontinence or constipation on a bowel management program with Peristeen® transanal colonic irrigation treated between 2007 and 2012 was performed. Irrigations were performed with a volume of 10–20ml/kg of water with schedules depending on patient response. Data are reported as median (range). Results: Twenty-three patients were reviewed. Median age at commencement of irrigations was 7 (2–15) years. Median follow-up is 2 (0.7–3.4) years. Diagnoses include the following: spina bifida (n =11), anorectal anomaly (n =6), Hirschsprung's (n =1), and other complex anomalies (n =5). Sixteen (70%) patients had associated anomalies. Twelve (52%) had constipation and overflow soiling, and 11 (48%) had fecal incontinence. Twenty (87%) had associated urinary wetting. Sixteen (70%) children used alternate-day irrigations, 4 (17%) daily irrigations, and 3 (13%) every third-day irrigations. Nine (39%) patients were taking oral laxatives. Sixteen (70%) reported to be clean and 3 (13%) reported a significant improvement, although were having occasional soiling. Four patients (17%) did not tolerate the irrigations and underwent subsequent colostomy formation for intractable soiling. Conclusions: In our experience, Peristeen® transanal colonic irrigation is an effective method of managing patients with focal soiling in childhood. Majority (83%) of children achieve social fecal continence or a significant improvement with occasional soiling. This was accompanied by high parental satisfaction. Peristeen® transanal colonic irrigation is a valid alternative to invasive surgical procedures and should be considered the first line of treatment for bowel management in children with soiling where simple pharmacological maneuvers failed to be effective. [Copyright &y& Elsevier]

Abstract: Purpose: Surgical options previously described by us as part of a bowel management program for the treatment of soiling and fecal incontinence include (1) resection of a megarectosigmoid to reduce a patient’s laxative requirement or (2) a Malone appendicostomy in patients who require enemas. We have found that some patients may benefit from both procedures. Methods: We reviewed 18 fecally incontinent patients with structural or functional disorders of the anorectosigmoid (16 ARM, 1 spina bifida, and 1 SCT) who underwent both procedures. Results: Of 18 patients, the enema regimen prior to resection had an average volume of 681ml of saline (Range 400–1000ml) and 60ml (Range 48–117ml) of additives (glycerine, castile soap and/or phosphate). Following the colon resection, the average volume of saline and additives was 335ml (Range 130–650ml) and 25ml (Range 0–60ml), respectively, a 50% reduction for both (P<0.01). The time for enema administration and evacuation was reduced by 25%, and the enemas were more effective, rendering the patients clean in 18 of 18 cases (follow-up was 3months to 21years). 2 patients later demonstrated that they could be managed with laxatives alone. Conclusion: In patients with poor continence potential and a megarectosigmoid, combining a colon resection with a Malone appendicostomy can make the enema more effective. In some rare cases we found the resection may allow for a better response to laxatives. [Copyright &y& Elsevier]

Abstract: Purpose: Longitudinal follow-up of changes in bowel function in children with anorectal malformations (ARMs) with or without spinal cord pathology and neurogenic bladder dysfunction (NBD) as they grow. Another purpose was to identify predictors influencing bowel functional outcome. Material and Methods: The study included 41 patients with ARM, excluding perineal fistula (21 boys and 20 girls). Bowel function was evaluated at ages 5, 10 and 15years using a structured questionnaire and a three-week registration of number and time of bowel movements, episodes of fecal leakage and soiling. Additional bowel treatment with enemas and stool softeners and use of diapers were recorded. A group of 52 healthy boys and girls was used as control. Results: A successive improvement in functional outcome with age in children with ARM and normal spinal cord was seen with respect to continence, soiling and constipation. Continence was achieved earlier in girls than in boys (at 10years: girls 80%, boys 36%). Soiling and constipation decreased with age both in grade and frequency (at 10years low grade soiling: girls 53%, boys 64%). Boys with spinal cord malformation with NBD in combination with prostatic/bladder neck fistula (PRF/BNF) and sacral agenesis had the worst functional outcome with minimal possibility of improvement over time. Functional outcome in girls with NBD and tethered cord did not differ significantly from those without NBD and with a normal spinal cord. Psychosocial co-morbidity, neuropsychiatric disorders, developmental delay and megarectosigmoid were also risk factors impeding the functional outcome. Conclusion: In the present study there was a successive improvement in bowel function during childhood and adolescence in ARM children, but they did not achieve the level of healthy children. NBD, spinal cord malformation, sacral malformation and PRF all were negative predictive factors for bowel score at 5years. [Copyright &y& Elsevier]

After surgery for Hirschsprungs disease, most children thrive, have few if any episodes of abdominal distention and enterocolitis, and are fecally continent. However, there exists a small group of patients who do not do well. Either they suffer from persistent distension and enterocolitis or they experience soiling after their pull-through procedure. These patients can be systematically evaluated and successfully treated with a combination of bowel management, dietary changes, and laxatives, and, in certain circumstances, a reoperation. [Copyright &y& Elsevier]

Abstract: Introduction: The antegrade continence enema (ACE) has been shown to be a safe and effective method for managing fecal incontinence in the pediatric population. The purpose of this study was to examine our experience with the ACE procedure using the appendix as a catheterizable conduit in children with anorectal malformations (ARMs). Methods: We reviewed the charts of all patients who underwent an ACE procedure using the appendix as a catheterizable conduit between January 1992 and January 2010. Preoperative diagnosis (ARM type), operative details, functional outcomes, and postoperative complications were assessed. Technical modifications over time included selective cecoplication, implementation of the umbilical V-V appendicoplasty technique, and laparoscopy for cecal mobilization. Results: Mean age was 9.9 ± 0.6 years, and 67% were male. The most common preoperative diagnosis was rectourethral fistula in boys (39%) and persistent cloaca in girls (61%). Forty-five complications occurred in 41 patients with an overall incidence of 25.6% (stricture, 18%; leakage, 6%; prolapse, 4%; intestinal obstruction, 0.6%). The incidence of stomal leakage was lower in patients when a cecoplication was performed (2.9% [4/138] vs 29.4% [5/17]; P < .01), and the incidence of stricture was lower in patients when the umbilical anastomosis was created using the V-V appendicoplasty technique (11% [11/100] vs 30% [18/60]; P < .01). Successful management of incontinence was reported by 96% of all patients. Conclusions: The ACE procedure using the umbilical V-V appendicoplasty provides an effective and cosmetically superior means for bowel management in children with ARMs. The rate of late complications is not insignificant however, and preventative strategies should focus on careful operative technique and ensuring compliance with catheterization protocols well past the initial postoperative period. [Copyright &y& Elsevier]

We describe the rationale and key aspects for success of a bowel management program for the treatment of pediatric fecal incontinence. A retrospective review was done of the medical strategies used for the treatment of over a 1000 patients with fecal incontinent, combining the experience of the authors'' previously published reports (Peña A, Guardino K, Tovilla JM, et al. J Pediatr Surg 1998; 33:133-137 and Bischoff A, Levitt MA, Bauer C, et al. J Pediatr Surg 2009; 44:1278-1284) and additional treated patients after those publications. Emphasis was placed on the review of the key factors needed to achieve success. Through the years, we have learned important lessons that resulted in our current strategy which allows us to obtain better results than earlier in our series. At present, the key aspects for success are (a) to distinguish between true fecal incontinence and pseudoincontinence; (b) to determine the characteristics of the colon (dilated or nondilated), ascertained by looking at the patient''s contrast enema, and determine the treatment strategy from this; (c) to monitor the result of the enema (amount of stool left in the colon) with daily abdominal radiographs during a 1-week period; and (d) to thereby modify the type of enema daily, depending on the clinical result, and the abdominal radiograph. Following a systematic rationale in the classification of patients with fecal incontinence and applying selectively, individualized management, it is possible to achieve a 95% success rate in patients suffering from fecal incontinence. [Copyright &y& Elsevier]

Ideally, after operative management of Hirschsprung disease, a child should thrive, avoid recurrent episodes of abdominal distention and enterocolitis, and be fecally continent. However, there is a small group of patients that do not do well after their pull-through procedure. The purpose of this article is to describe our algorithm for the work-up and management of the post pull-through patient with Hirschsprung disease who is not doing well. These children can be categorized into 2 distinct groups: (1) those who are soiling, and (2) those who suffer from distention and enterocolitis. Both of these patient types can be systematically treated with a combination of bowel management, dietary changes, and laxatives, and, potentially, a redo operation, with the goal of having a clean, and happy child. [Copyright &y& Elsevier]

Many families who have a child with spina bifida identify establishing an effective bowel program as one of the major challenges they face; yet, we know little about a family''s experience with this process. The purpose of this qualitative study was to describe the parent''s experience. Seven parents were interviewed by telephone. Content analysis yielded four themes: (a) long complicated journey, (b) the impact of the journey on the child, (c) the family struggle, and (d) the promise of the future. The major contribution of this study is a compelling description of one of the most difficult areas for these children and their families. A better understanding of this issue enhances the health care providers'' ability to deliver optimal health care. [Copyright &y& Elsevier]

Abstract: Introduction: Idiopathic constipation is a source of significant morbidity in children. A subset of patients is refractory to medical therapy and requires surgical intervention. We present a novel surgical technique for the management of these patients. Methods: We reviewed the records of 288 patients with severe idiopathic constipation and soiling. Patients who were refractory to medical management and had a megarectosigmoid underwent a transanal full-thickness rectosigmoid resection with a primary colo-anal anastomosis. Results: Fifteen patients underwent a transanal rectosigmoid resection. The preoperative contrast enema demonstrated an enormously dilated rectosigmoid in 14. An average of 43 cm (range, 8-98 cm) of rectosigmoid was resected. Of 14 patients with more than 3 months of follow-up, the preoperative laxative dose was 68 mg of senna/d (range, 52-95 mg), which decreased to 8.6 mg postoperatively (P < .001). Nine patients are clean without soiling, 1 is more prone to diarrhea, but is clean. Two patients soil occasionally, but are noncompliant, and 2 were lost to follow-up. Conclusion: Transanal rectosigmoid resection for medically intractable idiopathic constipation resulted in a dramatic reduction or elimination in laxatives use while preserving continence. It is a useful alternative to surgical options such as other colonic resections, antegrade enemas, and stomas. [Copyright &y& Elsevier]

Abstract: Purpose: Many articles describe the antegrade continence enemas (ACEs), but few refer to a bowel management program. A successful ACE may not help a patient without such management. Valuable lessons were learned by implementation of bowel management in 495 fecally incontinent patients. Methods: We previously reported 201 patients. Thereafter, another 294 patients participated in our program. On the basis of a contrast enema and symptoms, they were divided as follows: (a) 220 constipated patients and (b) 74 patients with tendency toward diarrhea. Colonic stool was monitored with abdominal radiographs, modifying the management according to the patient''s response and radiologic findings. For constipated patients, the emphasis was on using large enemas. For patients with tendency toward diarrhea, we used small enemas, a constipating diet, loperamide, and pectin. Diagnoses included anorectal malformation (223), Hirschsprung''s (36), spina bifida (12), and miscellaneous (23). Results: The management was successful in 279 patients (95%)—higher in constipated patients (98%) and less successful in patients with tendency toward diarrhea (84%). Conclusions: The key to a successful bowel management program rests in tailoring the type of enema, medication, and diet to the specific type of colon. The best way to determine the effect of an enema is with an abdominal film. The ACE procedures should be recommended only after successful bowel management. [Copyright &y& Elsevier]

Abstract: Purpose: Ideally, fecal incontinence after operative management for Hirschsprung disease should not occur. If it does, it presents a formidable challenge. The purpose of this study was to describe the causes of fecal incontinence and present our algorithm for its treatment. Methods: We reviewed 68 patients with Hirschsprung disease and fecal incontinence referred to us after surgery at other institutions. Patients were evaluated by contrast enema and by an examination under anesthesia to look specifically for the integrity of the anal canal. They were designated as having a dilated colon and constipation or a nondilated colon and a tendency to diarrhea based on their stooling pattern and the appearance of the contrast enema. Medical management was started that included laxatives for those patients with a dilated colon and constipation. For those with a nondilated colon and tendency to diarrhea, the management included loperamide, pectin, and a special dietary regimen (constipating diet, 3 meals per day, and no snacks). Those patients who responded to medical management were retrospectively considered to have been pseudoincontinent. Those who did not respond were considered truly incontinent. The truly incontinent group was treated with enemas alone for those with a dilated colon, or enemas, loperamide, pectin, and a constipating diet for those with a nondilated colon and tendency to diarrhea. Results: Fifty-six patients had true incontinence and 12 had pseudoincontinence. Of the true incontinent group, 27 had a dilated colon and 29 had a nondilated colon. Five of these patients had a damaged or absent anal canal (anastomosis at the anal skin) and all of them had true incontinence. In the dilated colon group with true incontinence, 23 (85%) patients were clean after treatment. In the nondilated colon group with true incontinence, 23 (79%) were successfully treated. All patients in the pseudoincontinent groups had no soiling after treatment. Of 55 in the truly incontinent group, 39 (70%) had had an endorectal (Soave type) pull-through. Conclusion: Fecal incontinence after operative management of Hirschsprung disease represents a serious problem. Poor surgical technique may be a contributing factor in some of the cases. Successful management depends on the appropriate evaluation, which determines whether the incontinence is true or pseudo, and the type of colon the patient has. Each category can be well treated, leading most of the time to a clean child. [Copyright &y& Elsevier]

The length of stay for patients undergoing joint arthroplasty has reduced but there is a paucity of knowledge relating to bowel management within this enhanced recovery framework. The study's primary aim was to determine which of two dosage regimens of macrogol (Movicol®) commenced pre-operatively is most effective in facilitating a return to normal bowel function. Ninety-one eligible patients were randomised to one of three groups: 1) commence macrogol one sachet in the morning for two days prior to surgery; 2) commence macrogol one sachet, morning and evening of the day prior to surgery; or 3) control group. Seventy-seven percent of patients in group one, and 83% of group two had returned to normal bowel function by one-week post discharge compared to 70% of control patients (p =.470). Participants in group one required less aperients in the week following discharge compared with the other two groups although the result was not statistically significant (p =.060). Despite not reaching statistical significance, the results are considered clinically significant. The authors recommend patients commence macrogol one sachet in the morning for the two days prior to admission for major joint arthroplasty and the Murdoch Bowel Protocol® continue to be followed for inpatients. [ABSTRACT FROM AUTHOR]

To examine the effects of bowel management on urodynamic findings in spina bifida children with detrusor overactivity (DO) and detrusor sphincter dyssynergia (DSD). Between 2014 and 2019 we prospectively evaluated 39 consecutive spina bifida children with DO and DSD (18 (46.2%) boys and 21 (53.8%) girls, aged 4–16 years; mean age 9.5 ± 3.7 years) who received bowel management and we treated their bowel dysfunction with an aim of alleviating the symptoms of constipation, preventing constant overdistension of the rectosigmoid, providing regular emptying of the colon and faecal continence. Bowel management included daily enema, laxative application and a special diet who was performed during 12 months. All children had undergone urodynamic studies before and after starting bowel management, with no changes in their urological treatment. Bowel management caused an increase in maximum bladder capacity from 183.0 (112.0–234.0) to 237.0 (165.0–298.0) (p < 0.001). When maximal bladder capacity adjusted for age there was also significant increment (adjusted before 0.54 (0.47–0.64), adjusted after 0.75 (0.70–0.82), p < 0.001). In addition, we observed a decrease in maximal detrusor pressure from 64.3 (49.0–77.0) to 46.4 (32.0–59.0) cm H2O (p < 0.001) and an increase in bladder compliance from 3.0 (2.0–3.3) to 5.6 (3.9–6.6) ml/cm H2O (p < 0.001). There was also significant reductions in leak point pressure from 62.0 (48.0–69.0) to 39.0 (30.0–43.0) cm H2O (p = 0.001), and significant reductions in post-void residual volume (PVR) from 165.0 (128.0–187.0) to 98.0 (68.0–136.0) ml in our 13 patients who could achieve spontaneous voiding (p = 0.001). Administering bowel management may be useful for bladder function and urodynamic findings in spina bifida children with DO and DSD. Therefore, bowel management should form an integral part of the treatment in spina bifida children with DO and DSD. Image 1 [ABSTRACT FROM AUTHOR]

The OEIS complex (ie, omphalocele-exstrophy-imperforate anus-spinal defects) is a rare and complex anomaly requiring collaboration among multiple pediatric surgical subspecialties throughout the early childhood period. Initial gastrointestinal management involves identification of all intestinal components with reconstruction of the entire length of intestines in-line leading to an end colostomy. Candidacy for an abdominoperineal intestinal pull-through procedure is dependent upon the patient''s ability to form solid stools, degree of pelvic neuromuscular development, and ability to comply with a bowel management program. [Copyright &y& Elsevier]

Summary Objective To examine the effects of bowel management on the frequency of urinary infections in spina bifida patients. Study design The research was carried out from 2014 to 2017, with the recruitment process from June 2014 to March 2016. The first group consisted of 35 patients who were administered bowel management combined with anticholinergic medication therapy and clean intermittent catheterization (CIC). The second group consisted of 35 patients who were treated only with anticholinergic medication therapy and CIC. Bowel management included daily enema, laxative application, and a special diet, with a view to treating constipation that was estimated on the basis of Roma III criteria and echosonographically determined transversal rectal diameter. The effects of the administered bowel management on urinary infections were estimated on the basis of the number of urinary infections before and after the administered therapy. The observation period of every patient was 1 year. Results There were no significant statistical differences regarding age, gender, and baseline clinical features between the two groups. In the group treated with bowel management combined with anticholinergic medication therapy and CIC, the average number of urinary infections was 0.3 ± 0.5 SD, whereas in the group treated exclusively with anticholinergic medication therapy and CIC the average number of urinary infections was 1.1 ± 1.0 SD. There was a statistical difference regarding urinary infections, that is the average number of urinary infections between these two groups of patients (p < 0.001). Conclusion Administering bowel management considerably decreases the frequency of urinary infections, and should form an integral part of treatment of spina bifida patients. Figure Average number of urinary infections in groups with and without bowel management. Figure [ABSTRACT FROM AUTHOR]