title: Clinical studies on anorectal myectomy for chronically constipated patients with outlet obstruction in childhood.
abstract: OBJECTIVE
  To clarify the significance of anorectal myectomy (ARM) for chronically constipated patients with outlet obstruction (CCPOO) in childhood, we analyzed the clinical features of theses patients before and after ARM.
  
  
  METHODS
  A consecutive series of one hundred and seven patients with CCPOO were included in this study. These were fifty-eight males and forty-nine females, aged between 0.2 and 15 years with a mean age of 8.9 years. We performed an analysis of the clinical findings and outcomes for CCPOO before and after ARM.
  
  
  RESULTS
  More than half of the patients were under the age of 6. Neurohistochemical study showed hypoganglionosis (Hypo) in 71 patients [mild type (3/5 or more ganglion cells per ganglia): 51 cases, severe type (less than 2/5 ganglion cells per ganglia): 20 cases], normal ganglia in 29, intestinal neuronal dysplasia (IND) in 2, and Hirschsprung's disease (HD; aganglionosis) in 5 (3 cases were residual HD after Soave's or Duhamel's operation). Most of the patients were Hypo, followed by those who were normal and finally those who had other histological types (HD and IND) in decreasing order. Mild Hypo was the most common compared with normal ganglia and HD (P<0.001, P<0.00001, respectively). Abdominal pain was the most common symptom, followed by soiling and anal pain. In addition, abdominal pain was the most common complaint in Hypo patients, and severe Hypo patients had abdominal pain more frequently than those with mild Hypo (P<0.05). The most common outcome after ARM was good (72.0%), followed by poor (15.9%) and satisfactory (12.1%) in decreasing order. There were significant differences between good and satisfactory, and between good and poor (P<0.0001, respectively). In addition, good was the most common outcome in mild Hypo patients compared with severe Hypo (P<0.0001). Poor was the most common outcome in severe Hypo patients compared with mild Hypo (P<0.001). Spontaneous evacuation was recorded in 72.7% of good outcome patients, and 38.5% of those with satisfactory outcome after ARM. Regarding the use of laxatives, there were significant differences between good and satisfactory, between satisfactory and poor, and between good and poor outcome (P<0.05, P<0.01, P<0.0001, respectively). Colonic, psychological or central nervous disorders were found at high rates in patients with poor outcome. The most common related cause of constipation after ARM was a redundant colon.
  
  
  CONCLUSIONS
  Hypo, IND, and HD may be largely related to defecation disorders observed in childhood CCPOO. CCPOO patients with colonic disorders, psychological or central nervous disorders may experience significant persistent constipation after ARM.
authors.affiliation: Department of Surgery, Nippon Dental University Hospital at Tokyo, 2-3-16 Fujimi Chiyoda-ku, Tokyo 102-8158, Japan. rtomita-ndus@mvg.biglobe.ne.jp
authors.forename: Ryouichi
authors.initials: R
authors.lastname: Tomita
authors.forename: Edward R
authors.initials: ER
authors.lastname: Howard
mesh_terms: D000293:Adolescent; D017668:Age of Onset; D002648:Child; D002675:Child, Preschool; D002908:Chronic Disease; D003248:Constipation / Q000209:etiology / Q000601:surgery*; D005260:Female; D006627:Hirschsprung Disease / Q000601:surgery*; D006801:Humans; D007223:Infant; D054368:Laxatives / Q000627:therapeutic use; D008297:Male; D009130:Muscle, Smooth / Q000601:surgery*; D012007:Rectum / Q000601:surgery*
chemical_list: D054368:Laxatives