Table 4

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

Age groupIndicationSurgical differentialsSurgery
ACE, antegrade continence enema; ARM, anorectal malformation.
NeonateConstipationHirschsprung diseasePatient wellRectal biopsy and wash out, planned pull through
Patient unwell, other compromising factorsRectal biopsy and diversion enterostomy followed by staged pull through
ARMAnal stenosis, perineal fistula, anal membranePrimary anoplasty/reconstruction
No perineal openingColostomy and staged reconstruction
Intra-pelvic mass/lesionExcision of the lesion as appropriate
ChildhoodConstipationPrevious operation for ARM, failure of medical treatmentAnal calibration/dilatation, disimpaction of stool
Previous surgery for Hirschsprung disease, failure of medical treatmentAnal dilatation, botulinum toxin, excision of residual/recurrent aganglionic segment, lateral sphincterotomy/ myectomy (and histology), ACE stoma*
Recurrent anal fissure failure of medical treatmentExcision of chronic anal fissure and histology
Severe faecal impactionDisimpaction of stool
Intra-pelvic mass/lesionExcision of the lesion as appropriate
Constipation and soilingMegarectum presentACE stoma±excision of megarectum
No megarectumConsider ACE stoma
Faecal incontinencePrevious anorectal malformation? MegarectumACE stoma±excision of megarectum, anal plug
Neuropathic bowel ± bladderACE stoma ± Mitrofanoff