This was a survey of management practices of pediatric surgeons on fecal incontinence in a country in sub-Saharan Africa. The design was cross-sectional and utilized case scenarios making it as practical as possible to simulate actual patient encounters. Hence, the responses could be approximated to what would likely happen to patient management under the care of the specialists. Another strength of the study was that 62% of the respondents were 45 years of age or younger; hence, this cohort is likely to be active in pediatric surgical practice for much longer. A major limitation was that the survey was deployed at a conference; hence, those who did not attend the conference were excluded, as a result of the methodology employed. A more comprehensive survey of all practicing pediatric surgeons in the country would have been more representative of the management practices regarding fecal incontinence. Nonetheless, this was the first of such survey in the region, and it provides a snapshot of the management of postoperative pediatric fecal incontinence. Another limitation was that the options given in the questionnaire could have limited the choices of the surgeons. However, there was an option of “other option,” which could have taken care of differences of opinion. Furthermore, in actual surgical practice, one may decide on different options based on circumstances at play. It is not unexpected that some of the options are preliminary to other choices.
Multiple modalities would be employed by 68% and 60% of the pediatric surgeons in the study for the management of patients with anorectal malformation and Hirschsprung disease, respectively, who develop postoperative fecal incontinence. Furthermore, there were no statistically significant differences based on the experience of pediatric surgeons in the adoption of multimodal treatment. The use of combination of treatment to solve the challenges of fecal incontinence is widely supported in the literature [2, 6, 9, 14,15,16]. A major recommendation in successfully treating patients with fecal incontinence is the need to differentiate between pseudo incontinence and true incontinence [6,7,8, 15]. Furthermore, the specialist should have an understanding of the colonic characteristic, largely obtained from clinical history and contrast enema, in each patient. Patients who are hypomotile, being prone to dilated, slow moving colon, are treated differently from those with hypermotile colon that is more likely to result in rapid transit of watery stools. Whereas hypomotile patients require large volumes of water for enema, hypermotile patients require smaller volume and less concentrated enemas. The use of different modalities in combination results in a significantly better response to the management of fecal incontinence [2, 9, 15].
Bowel management would be used by 81% and 84% of the respondents to manage fecal incontinence in patients with anorectal malformation and Hirschsprung disease respectively. This is encouraging as it shows a great deal of awareness of the role of bowel management in the treatment of pediatric fecal incontinence. Bowel management program is a set of processes or activities designed to keep a patient with fecal incontinence artificially clean without soiling the underwear in between enemas. The program consists of administration of enemas—retrograde or anterograde, dietary modification, and use of medications (to slow down the colon, e.g., loperamide, Smecta; or to provide bulk, e.g., pectin; or to stimulate motility, e.g., laxatives) [2, 14, 15, 17,18,19]. Bowel management, when utilized appropriately and adequately, individualized according to the patient’s age, type of incontinence, severity, and response to the treatment regimen [15], has been shown to be successful in 95% of pediatric patients with true fecal incontinence [2, 15].
Constipating diet was selected by 43.2% and 35.1% of the pediatric surgeons as methods of management of fecal incontinence occurring after surgery for anorectal malformation and Hirschsprung disease respectively. Constipating diet works on the basis of slowing down transit time within the colon. The use of constipating diet is likely to be successful in patients who had been clean on an enema regime. Constipating diet is most useful in patients with hypermotile colon with frequent loose stools [2, 16]. Patients who have had large colonic resections may also benefit from constipating diet.
A diverting colostomy will be used by 21.6% of the respondents to manage fecal incontinence after surgery for a patient with anorectal malformation and recto-bladder neck fistula. This requires further interrogation because a colostomy is not a first-line option in the management of patients with postoperative fecal incontinence. There are indeed a few indications for diverting colostomy in such patients: if the examination under anesthesia (EUA) and other investigations show an inadequate anoplasty that will be amenable to reoperation or if there is severe prolapse and the expertise for a single stage re-operation is not available. It is indeed noteworthy that 43.2% and 37.8% of the pediatric surgeons will perform an EUA in managing the patient with fecal incontinence postoperation for anorectal malformation and Hirschsprung disease respectively. The EUA will afford an opportunity to examine the size and location of the anoplasty within or outside the sphincter mechanism [6, 7]. The anal canal will be inspected during EUA in the patient who has had a pull-through operation to ascertain the intactness of the dentate line, which is a requirement for adequate proprioception and establishment of bowel control [5, 7]. A permanent colostomy is not supported, in the management of patients with anorectal malformation who developed fecal incontinence in order to ensure a good quality of life for affected patients [20].
