# Antegrade Continence Enema vs. Botulinum Toxin in Pediatric Chronic Idiopathic Constipation: A 10-Year Retrospective Study at a Single Center

## TL;DR

A 10-year study compared two treatments for chronic constipation in children, finding that both improved symptoms but with different trade-offs in effectiveness and healthcare use.

## Contribution

The study provides a long-term comparative analysis of ACE and BT in pediatric CIC, highlighting their differential impacts on laxative reduction and healthcare utilization.

## Key findings

- ACE resulted in a greater reduction in daily oral laxative use compared to BT.
- BT was associated with fewer postoperative healthcare visits and complications.
- Both treatments improved constipation-related symptoms like encopresis and abdominal pain.

## Abstract

What are the main findings?

Antegrade continence enemas (ACE) and Botulinum Toxin (BT) both improved oral laxative use and constipation-related symptoms at one year postoperatively from baseline.

ACE recipients had a greater reduction in oral laxative use, while BT was associated with fewer complications and healthcare utilization visits at 1 year postoperatively.

What is the implication of the main finding?

Decision-making for surgical interventions in pediatric CIC should be individualized and balanced between effectiveness and healthcare utilization.

Introduction: Chronic Idiopathic Constipation (CIC) is a common pediatric gastrointestinal disorder (GI) characterized by persistent difficulty in defecation, with no identifiable underlying cause. Although most patients are successfully treated with medical therapies, surgical intervention is often needed for refractory disease. We evaluated the impact of Antegrade Continence Enemas (ACE) and Botulinum Toxin (BT) injection to the internal anal sphincter on laxative use, symptom resolution, and healthcare utilization. Methods: A retrospective chart review was conducted to identify patients ≤ 18 years old presenting to a pediatric surgery clinic with a chief complaint of CIC between 1 March 2014 and 1 March 2024. Patients meeting the Rome IV criteria for idiopathic constipation and fecal incontinence were included. Surgical procedures were categorized into BT injection or ACE channel creation. The primary outcome was change in daily oral laxative use at 1 year, and secondary outcomes included symptom resolution and CIC-healthcare utilization at 1 year postoperatively. Results: Of the 125 children who presented with CIC, 47 (37.6%) underwent surgery. Mean age was 6 years at the time of surgery. 17 (36.2%) had ACE channel creation, while 30 (63.8%) received BT injections. At 1 year, daily oral laxative polypharmacy decreased from 60.2% to 41.0%, p < 0.001, with a greater reduction in ACE than BT (adjusted mean difference: −1.05, 95% CI: −1.75 to 0.34, p = 0.004) after adjusting for demographics and baseline clinical factors. Overall, symptom resolution of encopresis (79.1% to 39.5%, p = 0.001), abdominal pain (88.4% to 27.9%, p < 0.001), and abdominal distension (67.4% to 27.9%, p < 0.001) was observed with no significant difference between groups at 1 year. ACE patients had significantly more postoperative outpatient CIC-related visits and no change in ED visits compared to fewer visits in BT patients. Conclusions: Both ACE and BT recipients had improvements in constipation-related symptoms and laxative use. However, ACE resulted in a significantly greater reduction in daily laxative use and more postoperative CIC-healthcare visits than BT alone.