Surgical management of chronic unremitting constipation and fecal incontinence associated with megarectum: A preliminary report.

BACKGROUND/PURPOSE Functional constipation with associated fecal incontinence responds poorly to medical management once megarectum has developed. The authors describe resecting the dilated rectum and inserting a cecostomy button for antegrade enemas in this difficult condition. METHODS Four children, ages 9 to 15 years, with a history of unremitting constipation and fecal incontinence were referred for evaluation after not responding to medical management. All patients had exhibited normal lumbosacral magnetic resonance images (MRI) and open rectal biopsies; however, all 4 patients had a megarectum on contrast enema. In addition, anorectal manometry was consistent with functional fecal retention. The dilated rectum was resected by anastamosing the nondilated sigmoid colon to the distal rectum, and a standard gastrostomy button was inserted into the cecum for antegrade enemas. Mean follow-up was 35 months (range, 8 to 60 months). RESULTS Constipation and incontinence resolved within 6 months in all patients, and all children remained continent without the aid of cathartic agents. There were no postoperative episodes of fecal impaction. The only complication was antibiotic-associated diarrhea in 1 patient. Cecostomy buttons were removed at 1 year postplacement in all 4 patients with continued success. Three patients underwent repeat anorectal manometry; all 3 had normal rectal sensory threshold volumes and anorectal inhibitory reflexes. Barium studies also were obtained in the 3 patients without evidence of recurrent rectal dilation. CONCLUSIONS Refractory constipation and incontinence associated with megarectum may be amenable to surgical intervention in selected patients. The authors' limited experience suggests that proctectomy and button cecostomy is an effective treatment option that improves the quality of life in these patients. Furthermore, proctectomy alone may be curative.