Sigmoid Resection

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For the last 14 years, we have been performing a sig-moid resection for the treatment of these conditions [7,8]. The very dilated megarectosigmoid is resected and the descending colon is anastomosed to the rectum. In a recent review of patients with anorectal malformations, 315 suffered from severe constipation and were fecally continent, but required significant laxative doses to empty their colon. Of these, 53 underwent a sigmoid resection. The degree of improvement varied. Following sigmoid resection, 10% of patients did not require any more laxatives, have bowel movements every day, and do not soil. Thirty percent of patients decreased their laxative requirement by 80%. The remaining 60% of patients decreased their laxative requirement by 40%. These patients must be followed closely because the condition is not cured by the operation. The remaining rectum is most likely abnormal, and without careful observation and treatment of constipation, the colon can redilate. It is vital however in its role as a reservoir, and to allow the patient to feel rectal distension.

It is vital however in its role as a reservoir, and to allow the patient to feel rectal distension.

The most dilated part of the colon is resected because it is most seriously affected. The nondilated part of the colon is assumed to have a more normal mo-tility. Clearly, there must be a more scientific way to assess the dysmotile anatomy. Perhaps with emerging colonic motility techniques, these studies will help with surgical planning. It does seem that the patients who improve the most are those who have a more localized form of megarectosigmoid. Patients with more generalized dilatation of the colon do not respond as well. Perhaps in the future, these observations can be corroborated, and the results of resection better predicted by noninvasive modalities.

The administration of antegrade enemas through a continent appendicostomy or a button cecostomy is becoming popular [9]. Some clinicians use this approach, observe radiologically that the colon decreases in size over time, and then start laxatives. In our patients, we have only utilized antegrade enemas in incontinent patients who require a daily enema and seek more independence for their bowel management program [10]. An appendicostomy represents a useful alternative for patients who are treated with enemas only, since those antegrade enemas are only a different route of administration of enemas. It must be emphasized that the majority of patients with anorectal malformations and constipation can be treated with laxatives alone, provided it is in adequate doses, and on occasion benefit from a sigmoid resection. Therefore, most do not need washouts at all.

Distinguishing which patients require washouts because they cannot empty on their own from those who could empty if their constipation was adequately managed with laxatives is the key challenge for the clinician.

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Constipation Prescription

Constipation Prescription

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