Antegrade continence enema alone for the management of functional constipation and segmental colonic dysmotility (ACE-FC): A Pediatric Colorectal and Pelvic Learning Consortium Study

Abstract

Purpose: The purpose of the study is to determine if antegrade continence enema (ACE) alone is an effective treatment for patients with severe functional constipation and segmental colonic dysmotility. Methods: A retrospective study of patients with functional constipation and segmental colonic dysmotility who underwent ACE as their initial means of management were reviewed. Data was collected from six participating sites in the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC). Patients who had a colonic resection at the same time as an ACE or previously were excluded from analysis. Only patients who were ≤21 years old and had at least one year follow up after ACE were included. All patients had segmental colonic dysmotility documented by colonic manometry (CMAN). Patient characteristics including preoperative colonic and anorectal manometry were summarized, and associations with colonic resection following ACE were evaluated using Fisher’s exact test and Wilcoxon rank-sum test. P-values of <0.05 were considered significant. Statistical analyses and summaries were performed using SAS version 9.4 (SAS Institute Inc., Cary, NC, USA). Results: A total of 104 patients from six institutions were included in the study with an even gender distribution (males n=50, 48.1%) and a median age of 9.6 years (IQR 7.4, 12.8). At one year follow-up, 96 patients (92%) were successfully managed with ACE alone and eight patients (7%) underwent subsequent colonic resection for persistent symptoms. Behavioral disorder, type of bowel management, and the need for botulinum toxin administered to the anal sphincters was not associated with the need for subsequent colonic resection. On anorectal manometry, lack of pelvic floor dyssynergia was significantly associated with the need for subsequent colonic resection; 3/8, 37.5% without pelvic dyssynergia vs. 1/8, 12.5% (P=0.023) with pelvic dyssynergia underwent subsequent colonic resection. Conclusion: In patients with severe functional constipation and documented segmental colonic dysmotility, antegrade continence enema alone is an effective treatment modality at one year follow-up. Patients without pelvic floor dyssynergia on anorectal manometry are more likely to receive colonic resection after ACE. The vast majority of such patients can avoid a colonic resection.