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341 Summary and discussion although pain during transanal irrigation was reported by almost half of families, the vast majority (86%) of parents were satisfied with the result of transanal irrigation. These results show that transanal irrigation can prove to be a valuable tool in the treatment of intractable FC and that it should be considered in children refractory to pharmacological treatment and behavioral interventions. Part IV evolves around the surgical management of intractable FC. In chapter 14 , we assessed the diagnostic and surgical approach of pediatric surgeons and pediatric gastroenterologists towards children with intractable FC. We administered a survey to 74 physicians attending an international conference on colorectal diseases and motility disorders. Our results showed that the diagnostic and therapeutic approach towards children with intractable FC differed considerably among responders, even in a sample of physicians with expertise and interest in this field. We concluded that these results emphasize the need for a better understanding of the efficacy of surgical approaches in children with FC and of the role of diagnostic investigations in choosing the appropriate surgical treatment. In chapter 15 , we evaluated long-term efficacy of sacral nerve stimulation (SNS) in children with constipation who were followed up for more than 2 years after initiation of SNS treatment. In this sample of 25 children treated with SNS for constipation of various causes, we found that fecal incontinence had significantly improved. Moreover, a significant decrease in the proportion of patients using antegrade continence enemas was observed. Although a substantial amount of patients had complications requiring further surgery, 94% of interviewed parents indicated positive health-related benefit and all would recommend SNS to other families.We concluded that SNS can lead to durable improvement in symptoms and quality of life in children with constipation treated with SNS. However, a randomized sham-controlled trial with a long duration of follow-up is now required to establish a more widespread acceptance of this novel treatment modality. In chapter 16 , outcomes of surgical management in children with intractable FC at a single tertiary children’s hospital are presented. We performed a retrospective chart review of 37 children who underwent ileostomy, colostomy or (sub)total colectomy. Despite the fact that 81% of patients experienced stoma problems, with 12 patients (32%) requiring stoma- revisions, parental satisfaction was generally high. This seems contradictory, but in this subset of patients who are refractory to intensive medical treatment, these invasive surgical interventions seem to allow them to live a more normal life, resulting in an increased quality of life. Our results confirm reports from previous studies in small samples of patients. 50 Now it is time to initiate collaborative efforts to prospectively evaluate surgical outcomes in FC patients and to compare outcomes of different surgical approaches. In the future, this will hopefully result in guidelines to help clinicians choose the right treatment for their patients.