“Bowel Management” program for children with congenital malformations and neurogenic bowel after surgery

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Abstract

BACKGROUND: After the surgical treatment of children for anorectal malformations, spinal pathology, and Hirschsprung’s disease, their quality of life is significantly reduced due to fecal incontinence. For patients with persistent defecation disorders, the “Bowel Management” program is offered.

AIM: This study analyzes the “Bowel Management” program implemented in the clinic.

MATERIALS AND METHODS: A prospective analysis of the program used in children after surgical correction of malformations was conducted. The program comprised the following components: lectures for patients/parents, hospitalization, irrigography with water-soluble contrast, teaching patients/parents about cleansing enemas, keeping a bowel movement diary, plain abdominal X-ray, changing the recipe for enema solution, monitoring the effectiveness, and correcting recommendations.

RESULTS: A total of 66 children from 1.5 to 17 years old were treated. Three groups were identified: (I) anorectal malformations (n = 26), (II) spinal pathology (n = 30), and (III) Hirschsprung’s disease (n = 10). The results were considered satisfactory if the bowel cleansing procedure was painless for the child and did not cause stress reactions; the parents were satisfied with the result of the prescribed program if after the enema a sufficient amount of stool was removed within 45 minutes, there were no episodes of defecation during the day. With the help of the Rome IV revision criteria, fecal incontinence was noted in all cases against the background of stool retention. In 11 (16.7%), there was no fecal incontinence even in cases of prolonged stool retention. A correlation was found between “high” lesions (in the lumbar spine) in spinal hernias with the absence of fecal incontinence with prolonged stool retention compared with the “low” sacral localization of the hernia. In group I, 91.7% had spinal cord fixation. In group II, 86.7% had it, and none were present in group III. The effectiveness of the program was 83.3%.

CONCLUSION: The Bowel Management is easy to use and effective in 83% of patients. It can be recommended for the rehabilitation of children with defecation disorders, fecal incontinence after surgical correction of congenital malformations (anorectal malformations, spinal pathology and Hirschsprung's disease).

About the authors

Evgeniya S. Pimenova

I.M. Sechenov First Moscow State Medical University (Sechenov University); Speransky Children’s Hospital

Author for correspondence.
Email: evgeniyapimenova@list.ru
ORCID iD: 0000-0001-7206-5987
SPIN-code: 8694-6555

Cand. Sci. (Med.), pediatric surgeon

Russian Federation, 8, Trubetskaya str., 119991, Moscow; Moscow

Grigoriy A. Korolev

I.M. Sechenov First Moscow State Medical University (Sechenov University)

Email: KorolevG.a@yandex.ru
ORCID iD: 0000-0001-5730-3684
SPIN-code: 4315-0941

resident

Russian Federation, 8, Trubetskaya str., 119991, Moscow

Maxim V. Klementyev

Speransky Children’s Hospital

Email: klementmax1@list.ru
ORCID iD: 0000-0003-1214-7379
SPIN-code: 4125-9185

radiologist

Russian Federation, 8, Trubetskaya str., 119991, Moscow

Kulyash M. Kezhenbayeva

Speransky Children’s Hospital

Email: bowelmanagement@yandex.ru
ORCID iD: 0000-0002-0027-8921
SPIN-code: 4163-6836

radiologist

Russian Federation, 8, Trubetskaya str., 119991, Moscow

Olga E. Romanova

I.M. Sechenov First Moscow State Medical University (Sechenov University)

Email: Musa217058@yandex.ru
ORCID iD: 0000-0003-2898-1528
SPIN-code: 5963-7932

student

Russian Federation, 8, Trubetskaya str., 119991, Moscow

Dmitriy A. Morozov

I.M. Sechenov First Moscow State Medical University (Sechenov University); Speransky Children’s Hospital

Email: damorozov@list.ru
ORCID iD: 0000-0002-1940-1395
SPIN-code: 8779-8960

Dr. Sci. (Med.), professor, pediatric surgeon

Russian Federation, 8, Trubetskaya str., 119991, Moscow

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2. Fig. 1. Descriptive group statistics: (a) variants of anorectal defects and their frequency in group I; (b) variants of spinal pathology and their frequency in group II; (c) variants of aganglionosis and their frequency in group III; (d) the distribution of patients by age according to pathology, median age, and interquartile range in each group

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3. Fig. 2. Distribution of patients with different types of congenital malformations with stool retention combined with or without fecal incontinence: (a) the group of anorectal malformations; (b) the spinal pathology group; (c) the aganglionosis group; (d) contingency table (number of patients with constipation with or without fecal incontinence in all groups)

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4. Fig. 3. Characteristics of patients with different levels of meningomyelocele: (a–c) patient B., eight years old, after surgical correction of lumbar meningomyelocele and tethered cord. Complaints about stool retention up to 5–7 days, no fecal incontinence [(a) the appearance of the postoperative scar, black arrows indicate the distance from the localization of the scar to the anterior superior iliac spines (lat. spinae iliaca anterior superior); the angle between the lines approaches 180°; (b) contrast enema (200 ml of water-soluble contrast at a dilution of 1:5). The left colon is filled, not dilated, and a lot of dense fragmented feces is in the lumen; (c) a plain X-ray on the day after the enema (200 ml of saline + 5 ml of glycerin, after the enema, the colored water left). Incomplete emptying resulted in the contrast solution seeping into the overlying sections. The contrast is mainly in the rectosigmoid section. The enema recipe was changed to 300 ml saline + 20 ml glycerin]; (d–f) patient U., six years old, after surgical correction of the lumbosacral meningomyelocele tethered cord. The patient had complaints about stool retention, daily involuntary fecal incontinence in small portions (sheep-type feces) [(e) contrast enema (300 ml of water-soluble contrast at a dilution of 1:5). The rectosigmoid section is filled, slightly expanded, in the lumen of the sigmoid colon with a shadow of dense feces; (f) a plain X-ray on the day after the enema (300 ml of saline + 20 ml of glycerin, after the enema, a large amount of stool was present, but no accidents occurred). The emptying was sufficient. The enema recipe was accepted]

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