Effectiveness and Safety of Surgical and Advanced Interventional Treatments for Pediatric Refractory Constipation: A Systematic Review with Domain-Specific Meta-analyses of Proportions

Abstract

Objective: To synthesize clinical outcomes and safety of surgical and advanced interventional treatments for pediatric refractory constipation using a phenotype-directed, domain-specific approach. Methods: This systematic review with domain-specific meta-analyses of proportions followed PRISMA 2020 and was prospectively registered in PROSPERO (CRD420261378728). PubMed/ MEDLINE, Embase, Scopus, Web of Science, CENTRAL, the Cochrane Library, LILACS, trial registries, Google Scholar, and reference lists were searched through April 29, 2026. Eligible interventions included antegrade continence enema (ACE) procedures, botulinum toxin injection, transanal irrigation (TAI), diversion, and selected resective or motility-guided procedures. Random-effects single-arm proportions were pooled only within clinically coherent domains; safety outcomes were synthesized structurally when definitions and denominators were not sufficiently comparable for pooling. Results: Thirty-two primary interventional studies met final eligibility criteria, of which 22 contributed to quantitative synthesis. Descriptive pooled study-defined clinical success or response was 85% (95% CI: 81%-88%) for ACE procedures, 81% (95% CI: 72%-89%) for botulinum toxin injection, 81% (95% CI: 64%-94%) for TAI, and 91% (95% CI: 76%-100%) for resective or advanced surgery. The surgical estimate was exploratory because procedures and indications were heterogeneous. These proportions are not comparative treatment-effect estimates. Certainty of evidence was low or very low, and safety reporting was inconsistent across studies. Conclusion: Advanced interventions may be associated with favorable outcomes in carefully selected children with refractory constipation, but indications and risks are phenotype specific. The evidence does not support direct effectiveness comparisons between therapeutic domains.