Pediatric Surgery International

, Volume 24, Issue 7, pp 779–783

Botulinum toxin for the treatment of chronic constipation in children with internal anal sphincter dysfunction

  • Katy Irani
  • Leonel Rodriguez
  • Daniel P. Doody
  • Allan M. Goldstein
Original Article

Abstract

Internal anal sphincter (IAS) dysfunction is a cause of refractory constipation in children. The goal of this study was to determine whether intrasphincteric injection of botulinum toxin is effective in the treatment of constipation in pediatric patients with IAS dysfunction. A retrospective review was performed of 24 pediatric patients with intractable constipation. All patients had abnormal anorectal manometry, with either elevated IAS resting pressure (≥100 mm Hg) or an absent or diminished rectoanal inhibitory reflex. Patients with Hirschsprung’s disease were excluded. All patients underwent botox injection into the IAS and were followed for a minimum of 6 months. Of 24 patients, 22 experienced significant improvement in their constipation lasting greater than 2 weeks. The duration of effect was variable, with 12 patients demonstrating benefit lasting at least 6 months. Transient postoperative incontinence occurred in five patients. Intrasphincteric injection of botox is a safe and effective treatment for intractable constipation in children with IAS dysfunction.

Keywords

Constipation Anal achalasia Internal anal sphincter Botulinum toxin Anorectal manometry 

References

  1. 1.
    De Caluwe D, Yoneda A, Akl U, Puri P (2001) Internal anal sphincter achalasia: outcome after internal sphincter myectomy. J Pediatr Surg 36:736–738PubMedCrossRefGoogle Scholar
  2. 2.
    Messineo A, Codrich D, Monai M, Martellossi S, Ventura A (2001) The treatment of internal anal sphincter achalasia with botulinum toxin. Pediatr Surg Int 17:521–523PubMedCrossRefGoogle Scholar
  3. 3.
    Minkes RK, Langer JC (2000) A prospective study of botulinum toxin for internal anal sphincter hypertonicity in children with Hirschsprung’s disease. J Pediatr Surg 35:1733–1736PubMedCrossRefGoogle Scholar
  4. 4.
    Ciamarra P, Nurko S, Barksdale E, Fishman S, Di Lorenzo C (2003) Internal anal sphincter achalasia in children: clinical characteristics and treatment with Clostridium botulinum toxin. J Pediatr Gastroenterol Nutr 37:315–319PubMedCrossRefGoogle Scholar
  5. 5.
    Abbas Banani S, Forootan H (1994) Role of anorectal myectomy after failed endorectal pull-through in Hirschsprung’s disease. J Pediatr Surg 29:1307–1309PubMedCrossRefGoogle Scholar
  6. 6.
    Neilson IR, Yazbeck S (1990) Ultrashort Hirschsprung’s disease: myth or reality. J Pediatr Surg 25:1135–1138PubMedCrossRefGoogle Scholar
  7. 7.
    Kimura K, Inomata Y, Soper RT (1993) Posterior sagittal rectal myectomy for persistent rectal achalasia after the Soave procedure for Hirschsprung’s disease. J Pediatr Surg 28:1200–1201PubMedCrossRefGoogle Scholar
  8. 8.
    Simpson LL (1981) The origin, structure, and pharmacological activity of botulinum toxin. Pharmacol Rev 33:155–188PubMedGoogle Scholar
  9. 9.
    Jones OM, Brading AF, Mortensen NJ (2004) Mechanism of action of botulinum toxin on the internal anal sphincter. Br J Surg 91:224–228PubMedCrossRefGoogle Scholar
  10. 10.
    Pasricha PJ, Ravich WJ, Hendrix TR, Sostre S, Jones B, Kalloo AN (1995) Intrasphincteric botulinum toxin for the treatment of achalasia. N Engl J Med 332:774–778PubMedCrossRefGoogle Scholar
  11. 11.
    Maria G, Cassetta E, Gui D, Brisinda G, Bentivoglio AR, Albanese A (1998) A comparison of botulinum toxin and saline for the treatment of chronic anal fissure. N Engl J Med 338:217–220PubMedCrossRefGoogle Scholar
  12. 12.
    Maria G, Cadeddu F, Brandara F, Marniga G, Brisinda G (2006) Experience with type A botulinum toxin for treatment of outlet-type constipation. Am J Gastroenterol 101:2570–2575PubMedGoogle Scholar
  13. 13.
    Patti R et al (2006) Botulinum toxin vs. topical glyceryl trinitrate ointment for pain control in patients undergoing hemorrhoidectomy: a randomized trial. Dis Colon Rectum 49:1741–1748PubMedCrossRefGoogle Scholar
  14. 14.
    Keshtgar AS, Ward HC, Sanei A, Clayden GS (2007) Botulinum toxin, a new treatment modality for chronic idiopathic constipation in children: long-term follow-up of a double-blind randomized trial. J Pediatr Surg 42:672–680PubMedCrossRefGoogle Scholar
  15. 15.
    Rodriguez L, Flores A (2005) Internal anal sphincter achalasia: relationship with colonic dysmotility and manometric response to botulinum toxin injection. J Pediatr Gastroenterol Nutr 41:496Google Scholar
  16. 16.
    Freeman NV (1984) Intractable constipation in children treated by forceful anal stretch or anorectal myectomy: preliminary communication. J R Soc Med 77(Suppl 3):6–8PubMedGoogle Scholar
  17. 17.
    Holschneider AM, Shauer A, Meister P (1976) Results of spincteromyotomy in anal-spincter achalasia. Histology and postoperative continence. Chirurg 47:294–300PubMedGoogle Scholar
  18. 18.
    Heikkinen M, Lindahl H, Rintala RJ (2005) Long-term outcome after internal sphincter myectomy for internal sphincter achalasia. Pediatr Surg Int 21:84–87PubMedCrossRefGoogle Scholar
  19. 19.
    Brown SR, Matabudul Y, Shorthouse AJ (2006) A second case of long-term incontinence following botulinum injection for anal fissure. Colorectal Dis 8:452–453PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2008

Authors and Affiliations

  • Katy Irani
    • 1
    • 2
  • Leonel Rodriguez
    • 3
  • Daniel P. Doody
    • 1
  • Allan M. Goldstein
    • 1
  1. 1.Department of Pediatric Surgery, Pediatric Intestinal Rehabilitation ProgramMassachusetts General Hospital, Harvard Medical SchoolBostonUSA
  2. 2.Department of SurgeryNew York UniversityNew YorkUSA
  3. 3.Division of Pediatric Gastroenterology, Pediatric Intestinal Rehabilitation ProgramMassachusetts General Hospital, Harvard Medical SchoolBostonUSA

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