Damaged anal canal as a cause of fecal incontinence after surgical repair for Hirschsprung disease - a preventable and under-reported complication

INTRODUCTION

Fecal incontinence after the surgical repair of Hirschsprung disease is a potentially preventable complication that carries a negative impact on patient's quality of life.

METHODS

Patients that were previously operated for Hirschsprung disease and presented to our bowel management clinic with the complaint of fecal incontinence were retrospectively reviewed. All patients underwent a rectal examination under anesthesia looking for anatomic explanations for their incontinence.

RESULTS

One hundred three patients were identified. 54 patients had a damaged anal canal. 22 patients also had a patulous anus. The operative reports mentioned the pectinate line in 32 patients, in 12 it was not mentioned, and in 10 patients the operative report was not available. All patients with a damaged anal canal suffered from true fecal incontinence; 45 of them are on daily enemas (41 are clean and 4 are still having "accidents"), 7 are not doing bowel management due to noncompliance and 2 patients have a permanent ileostomy. 49 patients did not have a damaged anal canal, 25 of those responded to changes in diet and medication and are having voluntary bowel movements.

CONCLUSION

Fecal incontinence may occur after an operation for Hirschsprung disease. When the anal canal is damaged, incontinence is always present, severe, and probably permanent. The preservation of the anal canal may avoid this complication.

A standardized approach for the assessment and treatment of internationally adopted children with a previously repaired anorectal malformation (ARM)

INTRODUCTION

A significant number of internationally adopted children have congenital birth defects. As a specialist center for colorectal diagnoses, we evaluate such children with an anorectal malformation (ARM) and have found that a significant number need a reoperation. Knowledge of the common complications following ARM surgery has led us to develop treatment algorithms for patients with unknown past medical and surgical history, a situation typically encountered in the adopted population.

METHODS

The results of investigations, indications, and rate of reoperation were assessed for adopted children with an ARM evaluated between 2014 and 2016.

RESULTS

56 patients (28 males) were identified. 76.8% required reoperative surgery. Mislocation of the anus outside the sphincter complex was seen in 50% of males and 39.3% of females. Anal stricture, rectal prolapse, retained vaginal septum, and a strictured vaginal introitus were also common.

CONCLUSION

The reoperative surgery rate in the internationally adopted child with an ARM is high. Complete, systematic evaluation of these children is required to identify complications following initial repair. Development of mechanisms to improve the primary surgical care these children receive is needed.

Use of a Heineke-Mikulicz like stricturoplasty for intractable skin level anal strictures following anoplasty in children with anorectal malformations

INTRODUCTION

We introduced a modification of the Heineke-Mikulicz technique to treat intractable skin level anal strictures post posterior sagittal anorectoplasty (PSARP). The aim of this article is to describe the technique and outcome in a series of patients.

METHODS

This was a retrospective evaluation of patients who had Heineke-Mikulicz like stricturoplasty performed for a post PSARP skin level stricture over a one-year period.

RESULTS

Five patients who were operated using the technique were reviewed. All had severe anal strictures that could admit Hegar dilator sizes 6 to 9 at 16months to 5years after PSARP. All underwent routine dilatations, which became increasingly painful. As an alternative to continued dilatations, an operative procedure was offered. The surgery was done as a day case and lasted 10 to 30min. The anus at the end of the procedure could comfortably accept a Hegar dilator size 14 to 17. None of the patients had a colostomy after the procedure and there were no complications.

CONCLUSIONS

The Heineke-Mikulicz like stricturoplasty is a simple surgical procedure that can be done in an ambulatory setting to treat children with intractable skin level anal stricture if this develops following definitive surgery for anorectal malformations.

Surgical decision-making in the management of children with intractable functional constipation: What are we doing and are we doing it right?

BACKGROUND

Children with intractable functional constipation (FC) may eventually require surgery, often guided by motility testing. However, there are no evidence-based guidelines for the surgical management of intractable FC in children.

AIM

To assess the diagnostic and surgical approach of pediatric surgeons and pediatric gastroenterologists towards children with intractable FC.

METHODS

A survey was administered to physicians attending an international conference held simultaneously in Columbus (Ohio, USA) and Nijmegen (the Netherlands). The survey included 4 questions based on cases with anorectal and colonic manometry results.

RESULTS

74 physicians completed the questionnaire. Anorectal manometry was used by 70%; 52% of them would consider anal sphincter botulinum toxin injections for anal achalasia and 21% would use this to treat dyssynergia. Colonic manometry was used by 38%; 57% of them reported to use this to guide surgical decision-making. The surgical approach varied considerably among responders answering the case questions based on motility test results; the most commonly chosen treatments were antegrade continence enemas and anal botulinum injections.

CONCLUSION

Surgical decision-making for children with intractable FC differs among physicians. There is a need for clinical guidelines regarding the role of anorectal and colonic manometry in surgical decision-making in children with intractable FC.

Childhood constipation: finally something is moving!

Recent developments in the evaluation and treatment of childhood constipation are likely to influence the way we deal with pediatric defecation disorders in the near future. Innovations in both colonic and anorectal manometry are leading to novel insights into functional defecation disorders in children. Promising results have been achieved with innovative therapies such as electrical stimulation and new drugs with targets that differ from conventional pharmacological treatments. Also, new surgical approaches, guided by manometric findings, have led to improvement in patient outcome. Finally, utilization of non-pharmacological interventions such as fiber and probiotics has been a field of particular interest in recent years. The aim of this article is to provide an update on these and other novel diagnostic and therapeutic tools related to childhood constipation.

The association of the severity of anorectal malformations and intestinal malrotation

INTRODUCTION

Intestinal malrotation is a known association of anorectal malformations (ARM). Exact incidence, prognosis and surgical implications related to ARM are unknown. The aim of this study was to identify relevant associations between ARM and the presence of malrotation.

METHODS

Records of patients from two referral centers were retrospectively analyzed looking for malrotation associated to ARM and its management, as well as factors for functional prognosis.

RESULTS

40 patients out of 2572 with ARM (1.6%) were found to have malrotation. Females were more commonly affected, and severe malformations were more frequent (cloaca, covered cloacal exstrophy in females and rectoprostatic and rectobladder neck fistula in males). Factors significantly associated with malrotation included Müllerian or Wolffian duct anomalies (P<0.05), while fecal continence status, presence of constipation, and use of laxatives or enemas were not. Detecting and correcting malrotation early on or at the time of colostomy creation represented a protective factor against additional surgeries for bowel obstruction and volvulus (P<0.001). Removal of the appendix during malrotation treatment required constructing a neoappendicostomy using a cecal flap in 9 out of 14 patients needing antegrade enema administration.

CONCLUSIONS

Malrotation presence in patients with ARM has the same frequency as in the general population, but it is more common in severe malformations. Surgeons treating these patients should address the malrotation at the time of colostomy opening if detected. The appendix should be preserved for potential future use as an appendicostomy for antegrade administration of enemas.

Ectopic Pancreas in the Proximal Jejunum Associated with Duodenal Brunner's Gland Hyperplasia and Bile Duct Hamartoma

A case of a patient with ectopic pancreas in the proximal jejunum associated with duodenal bile duct hamartoma and Brunner's gland hyperplasia is described. The simultaneous finding of these discrete and uncommon lesions has not been previously reported and allows for speculation about a common embryologic origin.

The Posterior Sagittal Approach to Bladder Neck Closure in Patients With Anorectal Malformation: A Novel Collaborative Technique

Bladder neck closure may be beneficial in patients with refractory urinary incontinence secondary to outlet deficiency. The location of the bladder neck deep within the pelvis may make exposure difficult during an open approach. We describe a novel approach to bladder neck closure in patients with anorectal malformations using a posterior sagittal approach. Our approach provides superior visualization of the bladder neck and easy access to tissue to provide additional layers of coverage, and prevents the need for an abdominal incision in patients undergoing simultaneous rectal or vaginal surgeries.

Sacral nerve stimulation: a promising therapy for fecal and urinary incontinence and constipation in children

PURPOSE

This study describes our series of children with bowel and bladder dysfunction (BDD) treated with sacral nerve stimulation in order to begin to identify characteristics associated with better outcomes and guide future therapies.

METHODS

Between May 2012 and February 2014, 29 patients were evaluated before and after sacral nerve stimulator (SNS) placement. A prospective data registry was developed that contains clinical information and patient-reported measures: Fecal Incontinence Qualify of Life Scale, Fecal Incontinence Severity Scale, PedsQL Gastrointestinal Symptom Scale, and Vancouver DES Symptom Scale.

RESULTS

The median age of patients was 12.1 (interquartile range: 9.4, 14.3) years and the median follow-up period was 17.7 (12.9, 36.4) weeks. 93% had GI complaints and 65.5% had urinary symptoms while 7% had urologic symptoms only. The most common etiologies of BBD were idiopathic (66%) and imperforate anus (27%). Five patients required reoperation due to a complication with battery placement. Six of 11 patients (55%) with a pre-SNS cecostomy tube no longer require an antegrade bowel regimen as they now have voluntary bowel movements. Ten of eleven patients (91%) no longer require anticholinergic medications for bladder overactivity after receiving SNS. Significant improvements have been demonstrated in all four patient-reported instruments for the overall cohort.

CONCLUSIONS

Early results have demonstrated improvements in both GI and urinary function after SNS placement in pediatric patients with bowel and bladder dysfunction.

The Appendix and Aganglionosis. A Note of Caution-How the Histology Can Mislead the Surgeon in Total Colonic Hirschsprung Disease

We present the case of a child with presumed total colonic Hirschsprung disease (HD) to highlight the problems the surgeon is likely to encounter if he/she relies on the appendix alone for histopathologic diagnosis. A newborn male infant, who was presumed to have total colonic aganglionosis when the appendix was found to be aganglionic at the time of initial exploratory laparoscopy, was managed with an ileostomy in the newborn period; however, at the time of his planned pull-through procedure, the rectal biopsy revealed normal ganglion cells. The child was subsequently managed with ileostomy closure and observed for normal feeding and stooling prior to discharge home. We discuss the histopathologic findings of the appendix in separate cases of confirmed total colonic HD seen in our center, and review the normal histopathologic findings of the appendix.

The Gonzalez hernia revisited: use of the ischiorectal fat pad to aid in the repair of rectovaginal and rectourethral fistulae

INTRODUCTION

During the development of the posterior sagittal approach to anorectal malformations a vital technical challenge was a precise midline dissection, which if off, allowed for the ischiorectal fat pad to bulge into the wound. This occurrence became affectionately known as a "Gonzalez hernia", after a trainee of Dr Pena's (and a co-author of this paper). We describe here an innovative use of the ischiorectal fat pad to aid in the repair of acquired rectovaginal and rectourethral fistulae.

METHODS

Patients with recurrent vaginal or urethral fistulae were selected for review. The ischiorectal fat pad was deliberately mobilized (via a posterior sagittal or transanal approach) and used to buttress the repair of the posterior vagina or urethra.

RESULTS

The ischiorectal fat pad technique was used in 9 patients. All had an acquired fistula (6 rectovaginal fistula, 3 rectourethral fistulas). We used the posterior sagittal approach in 7 and in 2 the transanal approach. Six patients had had at least two prior attempts at fistula repair. Six patients had a stoma, and 3 did not. There were no recurrences in greater than six month follow-up.

DISCUSSION

The ischiorectal fat pad is easily visualized and mobilized, either via a posterior sagittal or transanal approach, providing excellent coverage with native, well-vascularized tissue, in an area that is difficult to heal. It is an excellent option for recurrent rectovaginal and rectovaginal fistulae and may have other additional creative applications.

The "rescue operation" for patients with cloacal exstrophy and its variants

INTRODUCTION

A common error in the initial operative management of patients with cloacal exstrophy is to create an ileostomy leaving the colon defunctionalized and connected to the urinary tract. These patients benefit from a "rescue operation" to give them the best opportunity to be future pull-through candidates.

METHODS

Nineteen patients were identified who underwent an inadequate diversion during the newborn period, leaving a distal defunctionalized colon, and required a "rescue operation". A retrospective review of the medical records of these patients was performed.

RESULTS

A piece of colon was disconnected from the urinary tract, rescued from the pelvis, and incorporated into the fecal stream. The original stoma was closed, and an end colostomy was created. Fifteen patients were females and four were males. The length of rescued colon ranged from 5.5 to 20 cm. Symptoms present before the operation included: hyperchloremic acidosis (6), urinary tract infections (6), failure to thrive (5), sepsis (1), dehydration (1), and TPN dependent (1). There was resolution of these symptoms post-operatively. On follow up, 10 patients still have their colostomies as we are waiting for continued colonic growth, 6 patients had a pull-through after responding to our bowel management program through the stoma, 2 patients have a permanent stoma, and one patient expired.

CONCLUSION

When patients with cloacal exstrophy, or its variants, receive an ileostomy or proximal colostomy at birth, a rescue operation should be attempted.

Creation of an appendicovesicostomy Mitrofanoff from a preexisting appendicocecostomy utilizing the spilt appendix technique

Continent catheterizable channels have revolutionized reconstructive surgery to achieve both urinary and fecal continence. The Mitrofanoff and Malone antegrade continent catheterizable channels offer improved quality of life relative to permanent incontinent stomas. A frequently employed surgical option for creating a Mitrofanoff when an existing appendicocecostomy exists involves harvesting a separate piece of intestine. If however the Malone has preceded the creation of a Mitrofanoff, we describe a surgical technique that may avoid the need for a bowel harvest and resultant anastomosis. We report our series of patients utilizing a novel alternative strategy in the select clinical circumstance of an existing appendicocecostomy to expand the armamentarium of the urologic reconstructive surgeon.

Transanal, full-thickness, Swenson-like approach for Hirschsprung disease

PURPOSE

Swenson's procedure for Hirschsprung disease (HD) was thought to disturb fecal, urinary, and ejaculatory functions leading to other approaches including the Soave and Duhamel techniques. Given our Center's experience with a full-thickness rectal dissection for anorectal malformations, and using the new transanal concept, we chose to apply these ideas to the primary treatment of HD, and describe technical aspects and impact on fecal, urinary, and sexual function.

METHODS

We reviewed our series of HD patients who underwent a transanal, Swenson-like rectosigmoid dissection, assessing for postoperative stricture, anastomotic leak, enterocolitis, and long-term results for bowel, urinary, and sexual function.

RESULTS

Of 67 patients, 28 had a transanal resection, 5 had transanal plus laparoscopy, and 34 had transanal plus laparotomy, of those, 28 patients had a leveling colostomy prior to referral. The average length of resection was 27 cm ± 12.7 cm. Mean follow-up was 17.2 months (range 1-96 months). 44 patients were at least three years old at follow-up and were assessed for urinary and fecal continence; all (100%) had voluntary bowel movements and urinary continence. Enterocolitis occurred in 9 patients (14%) and constipation (requiring laxatives) occurred in 21 (32%). Of 24 male patients, 21 (88%) reported the occurrence of spontaneous erections post-operatively.

CONCLUSION

Our data support the fact that a modification of Swenson's original transabdominal dissection concept using the recently described transanal approach is an excellent technique for Hirschsprung, and produces excellent long-term outcomes for fecal and urinary continence, and seems to preserve erectile function.

The role of a colon resection in combination with a Malone appendicostomy as part of a bowel management program for the treatment of fecal incontinence

PURPOSE

Surgical options previously described by us as part of a bowel management program for the treatment of soiling and fecal incontinence include (1) resection of a megarectosigmoid to reduce a patient's laxative requirement or (2) a Malone appendicostomy in patients who require enemas. We have found that some patients may benefit from both procedures.

METHODS

We reviewed 18 fecally incontinent patients with structural or functional disorders of the anorectosigmoid (16 ARM, 1 spina bifida, and 1 SCT) who underwent both procedures.

RESULTS

Of 18 patients, the enema regimen prior to resection had an average volume of 681 ml of saline (Range 400-1000 ml) and 60 ml (Range 48-117 ml) of additives (glycerine, castile soap and/or phosphate). Following the colon resection, the average volume of saline and additives was 335 ml (Range 130-650 ml) and 25 ml (Range 0-60 ml), respectively, a 50% reduction for both (P<0.01). The time for enema administration and evacuation was reduced by 25%, and the enemas were more effective, rendering the patients clean in 18 of 18 cases (follow-up was 3 months to 21 years). 2 patients later demonstrated that they could be managed with laxatives alone.

CONCLUSION

In patients with poor continence potential and a megarectosigmoid, combining a colon resection with a Malone appendicostomy can make the enema more effective. In some rare cases we found the resection may allow for a better response to laxatives.

Long-term follow-up of functional outcome in patients with a cloacal malformation: a systematic review

BACKGROUND

Reconstructive surgery is performed in patients with cloacal malformations to achieve anorectal, urological, and gynecological function. The aim of this study was to evaluate the functional outcome of cloacal malformation repair as reported in literature.

METHODS

A systematic literature search was conducted according to PRISMA guidelines using PubMed, EMbase, and Web-of-Science. Records were assessed for the reporting of functional outcomes, which was divided into anorectal, urological, or gynecological function. Studies were used in qualitative (Rangel score) and quantitative syntheses.

RESULTS

Twelve publications were eligible for inclusion. Voluntary bowel movements were reported in 108 of 188 (57%), soiling in 146 of 205 (71%), and constipation in 31 of 61 patients (51%). Spontaneous voiding was reported for 138 of 299 patients (46%). 141 of 332 patients (42%) used intermittent catheterization, and 53 of 237 patients (22%) had a urinary diversion. Normal menstruations were reported for 25 of 71 patients (35%). Centers with limited experience reported similar outcome compared to centers with more experience (≥1 patients/year).

CONCLUSION

In this review we present functional outcome of the largest pooled cohort of patients with cloacal malformations as reported from 1993 to 2012. Functional disturbances are frequently encountered in anorectal, urological, as well as gynecological systems. Reporting of functional outcome in these patients should improve to increase knowledge about long-term results in patients with this rare malformation and to reach higher study quality. Especially, sacral and spinal anomalies should always be reported given their impact on functional outcome. Specialized care centers may be of great importance for patients with rare and complex conditions.

Update on the management of anorectal malformations

Thirty-three years ago, on 10 August 1980, in Mexico City, the first patient with an anorectal malformation was operated on using the posterior sagittal approach. At that time it was not obvious that we were actually opening a "Pandora's box" that continues to give many positive surprises, a few disappointments, and the constant hope that each day we can learn more about how to improve the quality of life of children born with all different types of anorectal malformations. In November 2012, patient number 3000 in our database was operated in the city of Cochabamba, Bolivia; during one of our International Courses of Anorectal Malformations and Colorectal Problems in Children. The goal of this article is to give a brief update on the current management of patients with anorectal malformation, based on the multiple lessons learned during this period.

Treatment of adults with unrecognized or inadequately repaired anorectal malformations: 17 cases of rectovestibular and rectoperineal fistulas

STUDY OBJECTIVE

To analyze all cases of congenital rectovestibular and rectoperineal fistulas diagnosed and treated later in life, and to describe presenting complaints, treatment, and outcome.

DESIGN

Retrospective cohort study.

SETTING

Pediatric surgery departments of 3 major referral centers in the US and Europe.

PARTICIPANTS

Seventeen women with untreated or inadequately treated rectovestibular or rectoperineal fistulas.

INTERVENTIONS

Analyses of all eligible patients: charts were analyzed for the classification of the malformation, main complaints, continence, sexual function, indications for surgery, associated anomalies, surgical procedure, complications, and outcome.

MAIN OUTCOME MEASURES

Patients' complaints, continence, constipation, and sexual function.

RESULTS

Major complaints at time of diagnosis were fecal incontinence, and concerns for hygiene and cosmesis. All patients were repaired by a posterior sagittal approach. In all but 1 patient the complaints disappeared or improved after surgery.

CONCLUSIONS

Anorectal malformations in females are congenital malformations mostly seen and treated in early childhood. If unrepaired or inadequately repaired the patient, when reaching adulthood, can suffer from significant morbidity. Surgical treatment is similar as in childhood and has an excellent clinical outcome.

Vaginal switch--a useful technical alternative to vaginal replacement for select cases of cloaca and urogenital sinus

AIM

The aim of this study was to describe the indications, technical details, and complications of a surgical maneuver designed to repair the vagina in select cases of cloaca and urogenital sinus.

METHODS

A vaginal switch maneuver (VSM) is applicable when patients have two high large hemivaginas, and the distance between both hemiuteri is longer than the longitudinal length of the vaginas. It consists of resecting one hemiuterus and the vaginal septum, tubularizing both hemivaginas to create a single one, and switching down the vaginal dome of the side of the resected hemiuterus. Sixty patients who underwent this procedure were reviewed.

RESULTS

Mean common channel length was 5.2 cm. Complications occurred in twenty-six (43%) and included: acquired vaginal atresia that later required a vaginal replacement (n=11), introital stricture (n=6), incidental oophorectomy owing to damaged blood supply (n=4), vaginal-urethral fistula (n=3), partial vaginal dehiscence (n=1), and partial vaginal mucosal prolapse (n=1). In four cases VSM was unsuccessfully attempted owing to ischemia, and a partial vaginal replacement was performed. Forty-five patients (75%) were able to keep their native vaginal tissue as a vagina. Thirty patients are older than 12 years of age, and eight are menstruating.

CONCLUSION

The vaginal switch maneuver is a useful alternative to vaginal replacement. In spite of the morbidity, it is valuable because of the inherent advantages of preserving native vaginal tissue.

Laparoscopic-assisted PSARP - the advantages of combining both techniques for the treatment of anorectal malformations with recto-bladderneck or high prostatic fistulas

AIM

The aim of this study was to present an alternative way to use both the posterior sagittal approach combined with laparoscopy for the repair of select cases of anorectal malformation (ARM).

METHODS

The laparoscopic approach was used for rectal dissection, ligation of the fistula, and division of vessels to pull the rectum down in cases of ARM with recto-bladderneck or high prostatic fistula. The posterior sagittal incision we believe made the perineal portion safer, allowing for rectal tapering when necessary, and for accurate placement of the rectum, anchored in the center of the sphincter.

RESULTS

There were 15 children (recto-bladderneck fistula, n=13 and recto-prostatic fistula, n =2) in this series. There were no urethral injuries, posterior urethral diverticula, or rectal strictures. A laparotomy was needed in two children in order to mobilize a very high rectum. Follow-up ranged from 3 months to 10 years. Clinical results were consistent with our published series for male patients with these types of defects: 5 are fecally incontinent (3 are clean with a bowel management program), 1 is fecally continent, and 9 are too young to assess. Four children suffered rectal mucosal prolapse.

CONCLUSION

The combination of laparoscopy and PSARP represents a useful technical alternative that allows for a safe reconstruction in cases of ARM with recto-bladderneck and in selected high prostatic fistulas.

Celiac disease and diabetes mellitus diagnosed in a pediatric patient with Hirschsprung disease

Hirschsprung disease is a disorder of neural crest migration characterized by intestinal aganglionosis along a variable segment of the gastrointestinal tract. It is a complex disorder associated with several syndromes. Celiac disease is an autoimmune enteropathy characterized by dietary intolerance to gluten proteins and can be associated with autoimmune conditions such as diabetes mellitus. Celiac disease can mimic Hirschsprung disease when presenting with constipation and abdominal distention. We present the case of celiac disease diagnosed in a patient with Hirschsprung disease who subsequently developed type one diabetes mellitus.