Table 4

Summary of the surgical interventions for patients with severe constipation and/or incontinence

Age group	Indication	Surgical differentials		Surgery
ACE, antegrade continence enema; ARM, anorectal malformation.
Neonate	Constipation	Hirschsprung disease	Patient well	Rectal biopsy and wash out, planned pull through
			Patient unwell, other compromising factors	Rectal biopsy and diversion enterostomy followed by staged pull through
		ARM	Anal stenosis, perineal fistula, anal membrane	Primary anoplasty/reconstruction
			No perineal opening	Colostomy and staged reconstruction
		Intra-pelvic mass/lesion		Excision of the lesion as appropriate
Childhood	Constipation	Previous operation for ARM, failure of medical treatment		Anal calibration/dilatation, disimpaction of stool
		Previous surgery for Hirschsprung disease, failure of medical treatment		Anal dilatation, botulinum toxin, excision of residual/recurrent aganglionic segment, lateral sphincterotomy/ myectomy (and histology), ACE stoma*
		Recurrent anal fissure failure of medical treatment		Excision of chronic anal fissure and histology
		Severe faecal impaction		Disimpaction of stool
		Intra-pelvic mass/lesion		Excision of the lesion as appropriate
	Constipation and soiling	Megarectum present		ACE stoma±excision of megarectum
		No megarectum		Consider ACE stoma
	Faecal incontinence	Previous anorectal malformation	? Megarectum	ACE stoma±excision of megarectum, anal plug
		Neuropathic bowel ± bladder		ACE stoma ± Mitrofanoff