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317 16 Outcomes of surgical management INTRODUCTION Functional constipation (FC) is a common pediatric disorder with a worldwide prevalence ranging from 0.7% to 29.6%. 1 Although the majority of patients with FC respond well to conventional (non-)pharmacological treatment, a proportion of patients suffer from intractable FC. In tertiary care centers, 50% of children referred to a pediatric gastroenterologist recover within 5 years, with the majority of patients no longer taking laxatives. 2,3 Yet, after 10 years of intensive medical treatment, 20% of the children still suffer from severe symptoms of constipation, such as infrequent hard and painful stools and severe abdominal pain. 2 For these patients and their parents, intractable FC is a frustrating problem that significantly reduces quality of life and leads to school absenteeism. 4–6 Surgery has been described as a successful therapeutic solution in this subset of patients in whom conservative treatment has failed. 7–10 In their recent systematic review on surgical management in children with FC, Siminas et al . concluded that surgical interventions are based on low-quality evidence. 11 Currently, the choice for surgery is generally based on severity of symptoms, lack of response to intensive (non-)pharmacological treatment and results of diagnostic investigations. There is no consensus regarding the diagnostic work-up that is required for surgical decisionmaking. 11,12 Surgery is a treatment of last resort and shouldonlybe consideredafter a thoroughevaluation has ruled out treatable organic causes of constipation. Surgery is generally performed in a step-up approach, beginning with the least invasive procedure and proceeding to more invasive treatment options only after failure of the previous step. Since there are no guidelines for surgery in children with intractable FC, the choice of surgical intervention is challenging and the approach differs among centers. 13 Surgical options include botulinum toxin injections into the anal sphincter complex, anal sphincter myectomy, sacral nerve stimulation (SNS), creation of an access for administration of antegrade enemas, segmental or total colonic resection, and temporary/permanent diverting ileostomy, and colostomy. 11,14 The rationale for diversion via an ostomy is to relieve symptoms and to decompress the colon, giving the diverted colonic segment time to recover. Several studies have shown that diversion of a dysmotile colonic segment can lead to improvement of colonic motility in that segment. 7,9,15 Segmental and total colonic resections have also been described in this setting. Resection of the dilated and dysfunctional colonic segment can lead to improvement of symptoms and a better quality of life. 10,16,17 Since there is not much evidence on the success and possible shortcomings of surgical management of children with FC, the aim of this study was to describe our experience with surgical management in children with intractable FC.