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281 Surgical decision-making 14 INTRODUCTION Childhood constipation is a common problem in pediatric healthcare. It is characterized by infrequent bowel movements (<3 per week), hard and/or large stools, painful defecation and it is often accompanied by abdominal pain. 1 Approximately 75–90% of children with chronic constipation seen by a pediatric gastroenterologist suffer from fecal incontinence, caused by the leakage of soft stools around a large and hard fecal mass accumulated in the rectum. 2 In most cases, an organic cause for constipation is not found and affected children are diagnosed with functional constipation (FC). The reported prevalence of FC among children ranges from 0.7% to 29.6% with a mean female/male ratio of 2.1:1. 3 A subset of patients with FC experience severe and long-lasting symptoms that respond poorly to conventional behavioral, dietary and pharmacological management, these children are considered to have intractable FC. 1 In tertiary care centers, 50% of children referred to a pediatric gastroenterologist are still symptomatic after five years, and 20% still struggle with symptoms after 10 years. 1 Symptoms can even persist into adulthood despite intensive laxative treatment. 4 Persistent FC symptoms negatively affect quality of life in multiple ways (e.g., social interactions, school achievements, self-esteem) and account for significant associated healthcare costs. 5–7 Children with intractable FC may eventually require alternative therapeutic interventions including surgery. The most recent joint guidelines from the European Society of Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) state that colonic manometry may be indicated in children with intractable FC because evaluation of colonic motility may help guide surgical management. 1 This recommendation is mostly based on expert opinion and relies on the results of few retrospective studies that reported that normal colonic manometry predicts a successful response to antegrade continence enemas (ACE) 8  and abnormal manometry was associated with successful surgical interventions. 9 However, there are no guidelines that clearly recommend which surgical treatment should be performed based on manometry results. Without such guidelines, it is likely that the surgical approach towards children with severe FC differs among centers and among individual surgeons. Surgery is usually considered a treatment of last resort and is generally performed with a step-up approach, beginning with the least invasive treatment and progressing to more invasive interventions only if needed. The choice of what type of surgery to perform is usually determined based on a comprehensive evaluation of the colonic and anorectal anatomy and physiology, although this evaluation may differ among centers. Generally, medical care for children with intractable FC is a joint venture, where both pediatric gastroenterology