This document provides information on constipation in children, including definitions, prevalence, types (functional vs organic), and management. Some key points: - Functional constipation is more common than organic causes and typically starts after infancy. Chronic constipation accounts for 3-25% of pediatric GI visits. - Idiopathic constipation is a self-perpetuating condition where untreated stool retention leads to dilated bowels and worsening constipation. - Hirschsprung's disease is a rare cause of constipation characterized by absence of ganglion cells in parts of the bowel. Diagnosis involves biopsy and tests like barium enema. - Slow transit constipation involves prolonged

1. Constipation in children
By
Prof.Youssri Gaweesh
Professor of colorectal surgery
Alexandria university

2. Definition
Constipation is decreased frequency of bowel movements usually
associated with a hard stool consistency passed with difficulty
every 3rd day.
Functional constipation implies that there is no identifiable
causative organic condition
 Functional constipation typically starts after the neonatal
period

3. Chronic constipation
3% of the visits to general pediatrics.
25% of the visits to pediatrics G.I.
Functional / non organic is most common
Organic is rare ( except in infancy)

4. Idiopathic constipation
Idiopathic constipation is a self-perpetuating and self-
aggravating disease. A patient that has a certain degree of
constipation that is not adequately treated only partially
empties the colon throughout the day, leaving larger and
larger amounts of stool inside the rectosigmoid, which
results in greater degrees of megasigmoid.
Most surgeons accept that the dilatation of a hollow viscus
produces poor peristalsis which leads to dilatation. This
explains why constipation means fecal retention, which
produces megacolon that exacerbates the constipation.

5. Idiopathic constipation
In addition, the passage of large, hard pieces of stool may
produce painful anal lacerations (fissures), which result in a
reluctance by the patient to have bowel movements.
Consequently, if the patient was born with a certain degree
of constipation and does not receive proper treatment, the
constipation worsens and becomes an increasingly serious
problem.

6. Idiopathic constipation
The condition is mostly incurable, which means that these
patients must be monitored for life.
Unfortunately, treatments are frequently administered on a
temporary basis; they are then tapered or interrupted,
followed by a subsequent recurrence.
This creates a great deal of frustration for patients and
parents and may contribute to the well-known pattern of
patients who seek a solution from many different doctors or
clinics.

7. Idiopathic constipation
Another controversy involves symptom onset. Many doctors
believe that this problem starts during toilet training.
Although symptoms become more evident at that time, the
motility disorder is present at birth.
Breastfed babies may not show symptoms, because of the
well-known laxative effect of human breast milk.
When breastfeeding is discontinued and the patient receives
formula and other foods, the symptoms become obvious.
Babies who have constipation problems while breastfeeding
are likely to have severe constipation that will only worsen
over time. Some of these patients need to be checked for
Hirschsprung disease.

8. Functional constipation
Exclude red flag signs
Triggering events
The withholding behavior
Complications
Management
outcome

9. Red flag signs
Symptoms appearing from birth or during the first few
weeks of life
Delay in passing meconium for more than 48 hours after
birth in a full term baby
Abdominal distension with vomiting
Ribbon stool pattern
Abnormal appearance of anus (shape and site) with absence
of anal wink

10. Red flag signs
Weakness in legs or locomotor delay
Abnormalities in the lumbosacral or gluteal regions
Evidence of faltering growth and well being
(hypothyroidism)

11. Functional constipation
Triggering events
Painful defecation.
Postponing.
Toilet: unavailability, phobia, training technique.
Changes in diet, routine.
Stress.
Sexual abuse

12. Functional constipation
The withholding behavior
Present in about 30% of the children with functional
constipation.
Struggle against the urge to defecate
Contract anal sphincter and gluteal muscles,
Stand on their toes, assume unusual postures and cross their
legs

13. Complications
Enormous stools to the point of being “toilet-plugging-specials”
Significant pain and a prepassage stereotyped behavior of gluteal
tightening and posturing
Early satiety, small meals all day, irritability, and unpredictable
spasms of abdominal pain usually located in the lower abdomen.
Encopresis becomes increasingly frequent.
Painless rectal bleeding after defecation.
After the passage, symptoms generally resolve for a few days, then
recur.

14. Functional constipation
Complications
Fecal soiling ( encopresis).
Acquired megacolon
Acquired motility disorders of the distal colon
Decreased awareness of the urge to defecate.
Decreased amplitude of rectal contractions.
Lack of relaxation of the anal sphincter.
Psychosocial

15. Management of chronic constipation and
encopresis
The three phases of management:
complete evacuation or disimpaction
sustained evacuation to restore normal colorectal tone
weaning from intervention.
The success of each depends on the cooperation and
understanding of the parent and, when possible, the child.

16. Management of chronic constipation
and encopresis
The older child is encouraged to be involved by keeping a
sticker chart or calendar to document efforts, successes, and
failures.
They are encouraged to establish a “habit” of toilet use
independent of the rest of treatment.
Use a footstool for the child to maximize abdominal pressure
during the Valsalva maneuver.

17. Constipation due to intestinal disease
Organic diseases
Hirschsprung disease
Ultrashort segment HD
Neural dysplasia
Internal sphincter achalasia of neurogenic origin or myogenic
origin
Functional diseases (no definite pathology was elucidated)
Slow transit constipation with normal calibered large bowel
Slow transit constipation with megalarge bowel
Functional internal sphincter achalasia due to counteracting the
reflex inhibition of the internal sphincter by voluntarily
contracting the external sphincter

18. Hirschsprung disease
Hirschsprung disease or aganglionosis occurs in 1 in 5,000 births.
Male-to-female ratio is 4 to 1, and the incidence increases with longer
segments of disease.
The diagnostic lack of ganglion cells in the myenteric and submucosal
plexus of the bowel wall extends proximally from the internal anal
sphincter.
In among 80% of the involved children, the aganglionic segment does
not extend above the sigmoid.

19. Hirschsprung disease
Hirschsprung disease is a heterogeneous genetic disorder with risk
rates for siblings ranging from 3% with short segment disease to 25%
with a female who has long segment disease.
An autosomal dominant form occurs with mutation in the RET gene.
Syndromes associated with Hirschsprung disease include trisomy 21,
deletion of chromosome 13q, Smith-Lemli-Opitz, Waardenberg,
Laurence-Moon-Biedl-Bardet, congenital deafness, and congenital
central hypoventilation.

20. Hirschsprung disease
Difficulty with evacuation is present from birth;
Meconium is not passed in the first 48 hours of life in 40% of
involved infants.
Recurrent abdominal distension, emesis, failure to thrive,
and acute enterocolitis allow diagnosis of 60% of patients by
3 months of age.
The presence of early obstructive features, onset in infancy,
and nearly complete absence of encopresis distinguish
Hirschsprung disease from functional fecal retention.

21. Hirschsprung disease
On rectal examination, the aganglionic bowel is tight around
the finger and the rectal ampulla is not dilated.
A barium enema usually allows visualization of the transition
zone between the tonically contracted aganglionic segment
and the dilated proximal bowel.
The enema should be performed without preparation, which
distorts the distal anatomy.

22. Hirschsprung disease
The entire colon and some small bowel may be involved in
3%.
The aganglionic segment of bowel fails to relax because of
the absence of inhibitory neurons containing nitric oxide and
vasoactive intestinal peptide.

23. Hirschsprung disease
Manometric studies of the rectum demonstrate the failure of
the internal anal sphincter to relax when distended (negative
RAIR).
Confirmation of the diagnosis requires rectal biopsy (best is
the suction capsule biopsy).
The aganglionic bowel has nerve fibers staining for acetyl
cholinesterase (histochemical staining)

24. Variable
Functional (Acquired)
Hirschsprung Disease
Onset of constipation
after 2 yrs of age
At birth
Abdominal distension
Uncommon
Common
Poor weight gain
Rare
Uncommon
Anal tone
Normal
Normal
Rectal examination
Stool in ampulla
Ampulla is empty
Malnutrition
None
Possible
Anorectal manometry
Distension of the rectum
causes relaxation of the
internal sphincter
No sphincter relaxation or
paradoxical increase of
pressure
Rectal biopsy
Normal
No ganglion cells
Barium enema
Massive amounts of stool,
no transition zone
Transition zone, delayed
evacuation

25. Neuronal dysplasia
Neuronal dysplasia, in contrast to aganglionic disease, is
associated with increased numbers of ganglion cells
(hyperganglionosis) in the lower colon.
It may present throughout childhood with variable
constipation or features of pseudo-obstruction.
It is more frequent among children who have
neurofibromatosis and has been associated with MEN type
IIb due to glioneuromas of the intestinal tract.

26. Neuronal dysplasia (cont.)
Surgical intervention is individualized and based on the
severity of symptoms and manometric demonstration of
severely impaired rectal relaxation.
Reduced numbers of ganglion cells (hypoganglionosis)
usually is an acquired disease of ganglion cell destruction
seen in Chagas disease or paraneoplastic syndrome.
Sometimes fecal retention causes a sort of ganglionitis
causing loss of ganglia

27. Slow transit constipation
Patients which can be called the inertia constipation category
(slow transit constipation prolonged STT) two types of
patients can be easily distinguished.
Type one includes patients who proved to have normal large
bowel diameter may be with some extra looping of the sigmoid
or other regions of the colon (dolichocolon),
Type two that includes patients with mega large bowel, whether
it is only mega rectum, rectosigmoid , or megacolon.

28. Slow transit constipation
The differentiation between these two categories is done by
radiographic evaluation, barium or gastrographin enema and
double contrast.
There is dilatation that involves the rectum and/ or the large
bowel to the pelvic floor
The process involves or begins in the rectum. A rectal
diameter of 6.5 cm at the pelvic rim on lateral view defines
mega rectum

29. Slow transit constipation
Colonic inertia is defined as the failure of the colon to propel
stool towards the rectum, including failure to produce mass
movement of stool around the time of defecation.
Colonic motor activity is abnormal with reduced high
amplitude propagating contractions, and transit time through
the colon is prolonged
There is failure to enhance colonic phasic pressure activity by
a meal or stimulant, and impaired propagated colonic
contractile response to bisacodyl and cholinergic agents

30. Slow transit constipation
Transit-time studies are very helpful in the confirmation of
the presence of slow transit constipation (functional
constipation: FC)
It also differentiate the slow transit constipation from the
constipation predominant irritable bowel syndrome (C-IBS)
where the pellets are propagated to the left side of the colon
in normal time with slow transit at the rectosigmoid area

31. plain x-ray of cases showing markers scattered all over the colon
after 5 days. These patients required subtotal colectomy

32. plain x-ray of case showing
markers scattered all over the
colon after 5 days. This patient
responded to subtotal colectomy
plain x-ray of case showing
markers scattered all over the
colon after 7 days. This patient did
not improve after anorectal
myotomy and required subtotal
colectomy

33. Plain X ray showing radio-opaque markers in the rectum in obstructed
defecation (excluded from the study)

34. Rome III Criteria for Chronic (Functional) Constipation and ConstipationPredominant Irritable Bowel Syndrome (IBS-C)
Chronic constipation
• Symptom onset at least 6 months prior to
diagnosis
• Presence of symptoms for the last 3 months
• Loose stools are rarely present without the use
of laxatives.
• Fewer than 3 bowel movements per week
• Symptoms include 2 or more of the following
during at least 25% of defecations:
– Straining
– Lumpy or hard stools
– Sensation of incomplete evacuation
– Sensation of anorectal obstruction or
blockade
– Manual maneuvers to facilitate evacuation
IBS-C
Symptom onset at least 6 months prior to
diagnosis
• Recurrent abdominal pain or discomfort at
least 3 days per month in the last 3 months
associated with 2 or more of the following:
– Improvement with defecation
– Onset associated with a change in stool
frequency
– Onset associated with a change in stool form
(appearance)
• 1 or more of the following symptoms on at
least 25% of occasions for subgroup
identification:
– Abnormal stool frequency (<3/week)
– Abnormal stool form (lumpy/hard)
– Abnormal stool passage (straining/incomplete
evacuation)
– Bloating or feeling of abdominal distension
– Passage of mucous

35. If subtotal colectomy is decided, an ileosigmoid
side to side stapled anastomosis is recommended
to minimize the diarrhea problem; however the
occurrence of postoperative adhesive small
bowel obstruction should always be kept in
mind.

36. Patients with mega large bowel
The question is:
Are all megalarge bowel are of organic origin? as in the
following cases
 Ultrashort segment Hirschsprung disease
 Internal sphincter achalazia ,neurogenic and /or myogenic
 Neural dysplasia
Or some of the megalarge bowel are of functional origin
The answer is yes

37. Patients with mega large bowel
A contrast enema performed by using hydrosoluble material
(never barium) is the most valuable study to confirm the
diagnosis of idiopathic constipation. The dilatation of the
colon extends all the way down to the level of the levator
mechanism, which is recognized because it coincides with
the pubococcygeal line. The lack of dilatation of the rectum
below the levator mechanism (pubococcygeal line) should
not be interpreted as a transition zone or nondilated
aganglionic bowel.

38. Patients with mega large bowel
 Under normal circumstances, the anal canal and the part of the
rectum below the levator mechanism are collapsed by the effect of
the striated muscle tone from the sphincter mechanism. The
rectum above the anal canal is extremely dilated, as is the sigmoid.
The contrast enema in patients with idiopathic constipation
reveals different degrees of dilatation of the rectosigmoid, as is
expected in a spectrum-type condition. Most interestingly, a
dramatic size discrepancy is noted between a normal transverse
descending colon and an extremely dilated megarectosigmoid.
 These changes are actually the reverse from what is observed in
patients with Hirschsprung disease. The colon in a patient with
Hirschsprung disease is dilated only proximal to the aganglionic
segment, which remains non dilated.

39. Anorectal and Colonic Manometry
Anorectal manometry is used by many practitioners.
Traditionally, it is performed by placing a balloon in the rectum
while measuring the pressure of the anal canal. Under normal
circumstances, when the rectal balloon is inflated, the intra-anal
canal pressure decreases; this is described as the anorectal reflex
(RAIR). Pressure that does not decrease in the anal canal is
considered abnormal and is considered a sign of “lack of
relaxation of the internal sphincter.” This is also considered
diagnostic for Hirschsprung disease.

40. Anorectal and Colonic Manometry
If the patient’s rectum has no ganglion cells, the diagnosis of
Hirschsprung disease is confirmed. Alternatively, if the rectal
biopsy reveals ganglion cells, the patient has idiopathic
constipation. In patients with Hirschsprung disease, the
treatment is well established.

41. Anorectal and Colonic Manometry
The whole issue becomes more controversial when the rectal
manometry is critically scrutinized. The pressure recorded in
the lumen of the anal canal, supposedly generated by the
internal sphincter, is actually generated both by the internal
sphincter (smooth muscle) and by the striated voluntary
muscle mechanism (external sphincter and levator), which
surrounds the lower rectum and the anal canal around the
area of the internal sphincter. To date, no publication has
clarified this serious flaw in the interpretation of manometric
studies.

42. Anorectal and Colonic Manometry
Pressure in the anal canal is not the primary result of the
contraction of the voluntary sphincter mechanism. The
original manometric studies in animals were performed by
using muscle relaxants, which kept the voluntary muscle
mechanism paralyzed. Any changes in the pressure of the
anal canal, under those circumstances, could be attributed to
the effect of the smooth muscle (internal sphincter).
However, none of the clinical studies published have made
use of muscle relaxants.

43. Anorectal and Colonic Manometry
 In addition, the inflation of a balloon in the rectum is assumed to
produce tension on the rectal walls, which triggers some
mechanism that produces a decrease in pressure in the lumen of
the anal canal as a final result. However, patients who are
constipated have widely varying degrees of megarectosigmoid,
ranging from minimal to giant. The sizes of the balloons that are
used in manometric studies are never large enough to stretch giant
rectosigmoids. Thus, the inflation of a regular balloon may not be
enough to stretch the rectal wall in patients with megarectum, and
this underinflation may produce false results.
 Colonic manometry, which measures propagation of peristalsis
through the colon, has not yet reached a point of accuracy to
determine which specific part of the colon is working and which is
not.

44. Histologic Findings
 Rectal biopsies are usually performed with the specific purpose of
ruling outHirschsprung disease. The study is usually unnecessary
when the clinical picture and the radiologic findings are
characteristic of idiopathic constipation.
 Rectal biopsies are performed if the contrast enema reveals
findings that suggest aganglionosis or if the patient behaves in a
way that is clinically similar to a patient with Hirschsprung
disease. If the patient has episodes of enterocolitis and does not
soil, Hirschsprung disease is suspected. If the rectal examination
reveals an empty rectum and the patient is still impacted above
the reach of the finger, consider Hirschsprung disease and
perform a biopsy.

45. Mega large bowel of organic origin
The contrast study with an attempted defecation
(defecography) has been demonstrated to differentiate
between normal, patients with ultra short segment HD,
patients with intestinal neural dysplasia (IND), and different
types of internal sphincter achalazia.
As an alternative a contrast enema with straining and lateral
view of the rectum down to the pelvic floor can be used for
differentiation

46. Mega large bowel of organic origin
In the normal defecography in the lateral view there is
stretching and reestablishment of the anorectal angle with
internal sphincter relaxation thus the column of contrast is
seen to continue through the anal canal which looks to be at
the same straight line to the outside.
On the contrary, in cases of ultra short segment HD the
internal sphincter shows no relaxation and the anal canal
remains completely closed

47. Mega large bowel of organic origin
In cases where there is neurogenic internal sphincter
achalazia internal sphincter is showing non relaxation and is
possibly associated with the presence of a fecolith at the end
of the rectum.
Manometerically speaking, whereas the demonstration of
internal sphincter relaxations excludes the presence of HD,
the absence of the relaxation reflex is only pathognomonic
for HD when the anorectal fluctuations typical of the smooth
muscle cells of the internal anal sphincter are observed

48. Mega large bowel of organic origin
 On the other hand in cases of myogenic anal sphincter
achalsia there is minimal opening of the internal sphincter
giving a smooth cone shaped opening of the lower rectal end
with tight end of the anal canal and possible presence of
fecolith.
There is also smooth ballooning of the posterior wall of the
rectum.

49. Mega large bowel of organic origin
In patients with IND no pathognomonic morphology of the
relaxation reflex exists. The reflex mechanism may be
normal, rudimentary or absent.
The same is true for hypoganglionosis and immaturity of
ganglion cells. The internal anal sphincter sometimes also has
an elevated tone with an increased anorectal pressure profile.
This can be true in HD as well as in hypoganglionosis and
IND

50. Mega large bowel of functional origin
In case of functional internal sphincter achalazia there is deficient
opening of the anal canal due to counteracting the internal
sphincter relaxation by voluntary contraction of the external
sphincter with diverticulum like protrusion of the posterior rectal
pole with partial evacuation.
In these cases the RAIR reflex is showing inhibition of the
internal sphincter tone

51. Mega large bowel of functional origin
In these cases usually anorectal myectomy alone is curative
with the presence of ganglia in the myectomy specimen
If in these cases myectomy did not improve the condition,
the diagnosis of neural dysplasia is the usual outcome. It
responds to the pull through operation

52. There is abrupt stoppage of dye at the pelvic floor with the presence of
fecoli in the rectum as well as in the sigmoid. This is similar to what is
described in cases of ultrashort segment HD or in cases with neurogenic
internal sphincter achalazia. This patient was 6 years old and the rectoanal
inhibitory reflex (RAIR) was absent.

53. A male 11 years old the lateral view showed mega large bowel with no coning at the
lower rectal end. The RAIR was absent and the myectomy showed no ganglia and was
inefficient in relieving the condition. Ultra short HD or less probably neurogenic
internal sphincter achalsia were speculated as the most probable diagnoses.

54. A female 23 years old the lateral view of the barium showed megarectum only with
moderate coning at the lower end of the rectum. The anorectal myectomy proved
beneficial and curative to the case and showed the presence of ganglia and present
anorectal inhibitory reflex. This case can be an example of either functional or myogenic
internal sphincter achalazia.

55. First the case is a female almost 30 years old with perfect physical and mental
development, second the rectum is the only part of the large bowel affected , thirdly
there was no fecoli , and the posterior wall of the rectum showed no diverticular like
projection but only smooth posterior ballooning with no coning at the anorectal angle.
Her RAIR was absent, and no ganglia were detected in the myectomy specimen. Ultra
short segment Hirschsprung megarectum was the most probable diagnosis.

56. A classical ultrashort segment HD in the barium lateral view
demonstrating no relaxing lower rectal segment ( since dilatation did
not reach the pelvic floor) .
The patient was one year with retarded growth that improved
dramatically after the final operation. The RAIR was absent, and the
ganglia were not detected.

57. There is large bowel dilatation with very mild lower rectal coning and multiple fecoli and
smooth posterior rectal ballooning. The presence of positive RAIR and the also the
presence of ganglia makes the diagnosis of intestinal neural dysplasia a more probable
diagnosis than ultra short segment HD or internal sphincter neural achalazia.

58. Relation of the ganglia status to the
RAIR reflex
In most cases if the RAIR is negative, the ganglia are absent
denoting either ultrashort segment Hirschsprung or
neurogenic internal sphincter achalazia with superadded
ganglionitis
On the contrary , if the ganglia are present and the RIAR is
positive , the above lesions are excluded , and the most
probable diagnosis is functional achalazia ( megarectum
alone, with coning of the anal canal on barium study). This
responds to myectomy alone.
It also can exist with neural dysplasia, that only respond to
pull through operation

59. Relation of the ganglia status to the
RAIR reflex
If however , there were ganglia with a negative RAIR ,
possibilities of neurogenic internal sphincter achalazia
associated with neural dysplasia or other allied disorders is
possible.
Myectomy alone in these cases usually fail and a pull through
operation is needed

60. CONCLUSIONS
 In conclusion we advocate the following steps in managing
patients with chronic constipation after exclusion of any
possibility of obstructed defecation syndrome:
1. A contrast enema is mandatory as the initial step of evaluation
2. The patients are then categorized into either patients with normal
caliber of the rectum and colon or patients with mega rectum
with without mega colon
3. For patients with normal caliber of the colon a colon transit time
is mandatory before any decision of surgery is taken. This test is
cheap, can be repeated and of course the conventionally described
precautions are taken in its interpretations.

61. CONCLUSIONS
 If subtotal colectomy is decided, an ileosigmoid side to side
stapled anastomosis is recommended to minimize the
diarrhea problem; however the occurrence of
postoperative adhesive small bowel obstruction should
always be kept in mind.
 The anorectal manometric study is required for
investigational purposes.
 If mega large bowel is depicted, an ano-rectal myectomy is
done either posteriorly or laterally for a minimum distance
of 4 cm with biopsy taken for investigational purposes.

62. CONCLUSIONS
A minimum of a month should be left before a decision is
taken to proceed for the endorectal, abdominally assisted
pull through operation.
A stoma is advised in case of the pull through operation until
further investigations can provide evidence that the non use
of stoma is safe.
Almost all patients needs after the colure of stoma some sort
of stool softeners and regulation of daily eating and bowel
habits to avoid encopresis which is very common in patients
below 10 years of age.

63. Anorectal myotomy and biopsy
2 stay sutures are taken at 4, 8 o'clock 1.5cm above
the dentate line to the skin including only the mucosa
and submucosa.

64. Anorectal myotomy and biopsy
A shelf of mucosa is created posteriorly under which
10ml 1: 300,000 adrenaline in saline is injected
submucosly.
Incision with raising a mucosal flap is done

65. Anorectal myotomy and biopsy
Raising a mucosal flap is done as far the finger can reach
(across to the 3rd sacral piece) to demonstrate the
internal sphincter and circular muscle layer of the rectum.

66. Anorectal myotomy and biopsy
A myotomy is done in the circular muscle layer using
scissor or low voltage diathermy with a length of about
8-10 cm
Biopsies are taken from extreme upper edges
of the myotomy

67. Anorectal myectomy and biopsy
a strip 0.5cm width of the muscular rectal wall
starting 1cm above the dentate line

68. Anorectal myectomy and biopsy
a length of 8-10cm and this is taken all as a
biopsy after demarcating its upper end
with a stitch.

69. Anorectal myectomy and biopsy
Closure of the transverse mucosal wound is
done after reassuring hemostasis and a small
pack is inserted for 12 hours

72. Trans-rectal abdominally assisted pull
through operation

75. Another case of transrectal abdominally
assisted pull through
operation

78. Is there other surgical options for mega
large bowel?
The idea of subtotal colectomy with ileorectal anastomosis is
not logic in the presence of mega rectum
The operation entailing total proctocolectomy with ileal
pouch anal anastomosis is too big for a benign lesion, also
exposing the patient to temporary diversion, deep pelvic
dissection with autonomic nerve jeopardy.
The operation suggested in the literature is known as vertical
reduction rectoplasty (VRR). It entails dissection in the
pelvis to mobilize the rectum, vertical excision of part at the
anti-mesenteric border ( anteriorly), and end to end or to
side anastomosis of what is left from the sigmoid (partial
sigmoidectomy is done)to the rectal remnant.

79. Line of a linear stapler
applied anteriorly after
mobilizing the rectum
VRR first step is to mobilize the rectum and
reduce its capacity by a linear stapler 10cm

80. VRR the second step is to
anastomose what is left
from the sigmoid to the
reduced rectal stump using
a circular end to end
anastomosis device.
The site of the anterior staples
It is better to do the anastomosis more
posterior away from the anterior
stapler line.

81. Sigmoid resection
 Sigmoid resection may be indicated in a small subset of patients who are
continent but have a huge laxative requirement.
 In this group of patients, if a megasigmoid is revealed by using a contrast
enema, a sigmoid resection can be performed to reduce the laxative
requirement and improve quality of life.
 The most dilated part of the colon is resected because that part of the
colon is believed to be most seriously affected. The nondilated part of
the colon is assumed to have normal motility, which is why the surgeons
use it to anastomose to the rectum. The very distal rectum is preserved.
This can best be done laparoscopically.

82. Sigmoid resection
Sigmoid resection is best accompanied by VRR , otherwise,
anastomosing the colon to a dilated rectum can eliminate the
benefits of sigmoidectomy.
Performing a sigmoid resection in a patient who is
incontinent with constipation is a major error. When the
sigmoid is removed, the patient becomes incontinent with
loose stools, a state that is much more difficult to manage.

83. Appendecostomy or cecostomy
In patients who are fecally incontinent, a bowel management
program with a daily enema is the correct treatment. The
rectal route may be problematic in older children who
require enemas: they tend to seek independence and do not
want their parents to give them enemas. In these patients, a
continent appendicostomy (Malone procedure) or cecostomy
for antegrade rectal washout can be performed.

84. Appendecostomy or cecostomy
The operation involves connecting the appendix to the
abdominal wall and fashioning a valve mechanism that allows
catheterization of the appendix but avoids leakage of stool
through it.
Some authors insert a cecostomy tube, which requires a
synthetic tubing material that enters the cecum for the same
goal of performing enemas. Both procedures have been
laparoscopically performed. Occasionally, if the patient has
had the appendix removed, a neoappendix can be created
with a cecal flap.

85. Appendecostomy or cecostomy
Regular follow-up and reassessment is necessary. Often, the
volume of enema needs adjustment. Rectal examination and
abdominal radiography help the surgeon assess the actual
cleanliness of the colon.
Complications of appendicostomy include stricture and
leakage, which usually require a revision of the stoma.