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Bokova E, Elhalaby I, Svetanoff WJ, Lawal TA, Levitt MA, Lim IIP, Rentea RM. Global Strategies for Postoperative Care and Bowel Management in Patients With Anorectal Malformations: Varied Practices and Barriers. J Pediatr Surg 2024; 59:161697. [PMID: 39256064 DOI: 10.1016/j.jpedsurg.2024.161697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Revised: 08/14/2024] [Accepted: 08/14/2024] [Indexed: 09/12/2024]
Abstract
BACKGROUND Anorectal malformations (ARMs) commonly result in constipation and fecal incontinence following primary surgical reconstruction. This study investigates global variations in postoperative care and resources. METHODS A survey was distributed via the International Pediatric Endosurgery Group (IPEG) and snowball sampling. Geographically, respondents were categorized into high-income countries (HICs) and low-or middle-income countries (LMICs). RESULTS 233 surveys were received, 64% from LMICs and 36% from HICs. Of these, 51% reported monitoring ARM patients for over a year, while 23% utilized digital technologies. Access to anesthesia for anorectal exams was available to 70% of respondents. Only 29% had established a one-week Bowel Management Program (BMP). Collaboration with urologists and gynecologists was more prevalent in HICs (59%) compared to LMICs (37%, p < 0.01). In HICs, nurses and advanced practice providers were significantly more involved in BMP (71% vs. 39% in LMICs; p < 0.01), and abdominal radiographs for regimen adjustments were used more frequently (80% vs. 69% in LMICs; p = 0.03). Treatment regimens were more varied in HICs, and quality of life tracking was more consistent (19% vs. 9% in LMICs; p = 0.02). LMICs reported significant shortages of medications and equipment (75% vs. 58% in HICs; p = 0.01), inadequate sanitation (48% vs. 24%; p < 0.01), and insufficient insurance coverage (58% vs. 44%; p = 0.04). CONCLUSIONS There are notable global disparities in the postoperative care of ARM patients, particularly in BMP protocols and treatment regimens, with LMICs facing severe socioeconomic challenges. This emphasizes the urgent need for targeted strategies and resources to enhance outcomes for ARM patients across different regions. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Elizaveta Bokova
- Comprehensive Colorectal Center, Section of Colorectal and Pelvic Reconstructive Surgery, Department of Pediatric Surgery, Children's Mercy Kansas City, Kansas City, MO, 64108, USA
| | - Ismael Elhalaby
- Comprehensive Colorectal Center, Section of Colorectal and Pelvic Reconstructive Surgery, Department of Pediatric Surgery, Children's Mercy Kansas City, Kansas City, MO, 64108, USA; Tanta University Hospital, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Wendy Jo Svetanoff
- Comprehensive Colorectal Center, Section of Colorectal and Pelvic Reconstructive Surgery, Department of Pediatric Surgery, Children's Mercy Kansas City, Kansas City, MO, 64108, USA
| | - Taiwo A Lawal
- Division of Pediatric Surgery, University College Hospital and Department of Surgery, University of Ibadan, Ibadan, Nigeria
| | - Marc A Levitt
- Division of Colorectal and Pelvic Reconstruction, Children's National Medical Center, Washington, DC, 20001, USA
| | - Irene Isabel P Lim
- Comprehensive Colorectal Center, Section of Colorectal and Pelvic Reconstructive Surgery, Department of Pediatric Surgery, Children's Mercy Kansas City, Kansas City, MO, 64108, USA; Department of Surgery, University of Missouri-Kansas City, Kansas City, MO 64108, USA
| | - Rebecca M Rentea
- Comprehensive Colorectal Center, Section of Colorectal and Pelvic Reconstructive Surgery, Department of Pediatric Surgery, Children's Mercy Kansas City, Kansas City, MO, 64108, USA; Department of Surgery, University of Missouri-Kansas City, Kansas City, MO 64108, USA.
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Ambartsumyan L. Medical management of anorectal malformations. Aliment Pharmacol Ther 2024; 60 Suppl 1:S77-S84. [PMID: 38924569 DOI: 10.1111/apt.17897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 11/28/2023] [Accepted: 01/26/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Anorectal malformations (ARMs) are congenital anomalies of the anorectum and the genitourinary system that result in a broad spectrum of hindgut anomalies. Despite surgical correction patients continue to have late postoperative genitourinary and colorectal dysfunction that have significant impact on quality of life. AIM This paper will review the current evidence and discuss the evaluation and management of postoperative patients with ARMs who present with persistent defecation disorder. METHODS A literature search was conducted using PubMed/MEDLINE/EMBASE databases applying the following terms: ARMs, imperforate anus, constipation, faecal incontinence, neurogenic bowel, posterior sagittal anorectoplasty. RESULTS Patients who present with postoperative defecation disorders require timely diagnostic and surgical evaluation for anatomic abnormalities prior to initiation of bowel management. Goals of management are to avoid constipation in young children, achieve faecal continence in early childhood and facilitate independence in older children and adolescents. Treatment options vary from high dose stimulant laxatives to high-volume retrograde and antegrade enemas that facilitate mechanical colonic emptying. CONCLUSIONS Appropriate diagnostic work-up and implementation of treatment can decrease long-term morbidity and improve quality of life in postoperative patients with ARMs who presents with defecation disorders.
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Affiliation(s)
- Lusine Ambartsumyan
- Division of Gastroenterology and Nutrition, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington, USA
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Bokova E, Svetanoff WJ, Lopez JJ, Levitt MA, Rentea RM. State of the Art Bowel Management for Pediatric Colorectal Problems: Anorectal Malformations. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10050846. [PMID: 37238394 DOI: 10.3390/children10050846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/28/2023] [Accepted: 05/04/2023] [Indexed: 05/28/2023]
Abstract
Up to 79% of patients with anorectal malformations (ARMs) experience constipation and/or soiling after a primary posterior sagittal anoplasty (PSARP) and are referred to a bowel management program. We aim to report the recent updates in evaluating and managing these patients as part of the manuscript series on the current bowel management protocols for patients with colorectal diseases (ARMs, Hirschsprung disease, functional constipation, and spinal anomalies). The unique anatomic features of ARM patients, such as maldeveloped sphincter complex, impaired anal sensation, and associated spine and sacrum anomalies, indicate their bowel management plan. The evaluation includes an examination under anesthesia and a contrast study to exclude anatomic causes of poor bowel function. The potential for bowel control is discussed with the families based on the ARM index calculated from the quality of the spine and sacrum. The bowel management options include laxatives, rectal enemas, transanal irrigations, and antegrade continence enemas. In ARM patients, stool softeners should be avoided as they can worsen soiling.
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Affiliation(s)
- Elizaveta Bokova
- Comprehensive Colorectal Center, Department of Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA
| | - Wendy Jo Svetanoff
- Comprehensive Colorectal Center, Department of Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA
| | - Joseph J Lopez
- Comprehensive Colorectal Center, Department of Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA
| | - Marc A Levitt
- Division of Colorectal and Pelvic Reconstruction, Children's National Medical Center, Washington, DC 20001, USA
| | - Rebecca M Rentea
- Comprehensive Colorectal Center, Department of Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA
- Department of Surgery, University of Missouri-Kansas City, Kansas City, MO 64108, USA
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Garvey EM, Fuller M, Frischer J, Calkins CM, Rentea RM, Ralls M, Wood R, Rollins MD, Avansino J, Reeder RW, Durham MM. Multi-Institutional Review From the Pediatric Colorectal and Pelvic Learning Consortium of Minor Spinal Cord Dysraphism in the Setting of Anorectal Malformations: Diagnosis, Treatment, and Outcomes. J Pediatr Surg 2023:S0022-3468(23)00251-8. [PMID: 37248140 DOI: 10.1016/j.jpedsurg.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 04/18/2023] [Indexed: 05/31/2023]
Abstract
BACKGROUND/RATIONALE Anorectal malformations (ARM) are associated with congenital anomalies of the spine, but the impact of a minor spinal cord dysraphism (mSCD) on fecal continence in the setting of ARM remains unclear. MATERIALS/METHODS A retrospective review was performed utilizing data from the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC) registry. The patient cohort was reviewed for ARM type, mSCD screening/incidence/neurosurgical intervention and age-based BMP utilization. RESULTS 987 patients with ARM were categorized into mild (38%), moderate (32%) or complex (19%). 694 (70%) had normal spinal (NS) status. 271 (27.5%) patients had mSCD. MRI alone (49%) was the most common screening test for mSCD. US screening had a positive predictive value of 86.3% and a negative predictive value of 67.1%. Surgical intervention rates for mSCD ranged between 13% and 77% at a median age of 0.6-5.2 years. 726 (73.6%) patients were prescribed BMP (74.4% NS, 77.5% mSCD). Laxatives were most utilized BMP in all groups <5yo. ≥5yo, enema utilization increased with ARM complexity independent of spine status (with or without neurosurgical intervention). Neurosurgical intervention did not affect BMP utilization at any age or with any ARM when mSCD was identified. CONCLUSIONS MSCD influence on bowel function in the setting ARM remains unclear. No significant impact of mSCD was noted on ARM patient bowel management program utilization. Variability exists within PCPLC site with screening and intervention for mSCD in patients with ARM. Future studies with standardized care may be needed to elucidate the true impact of mSCD on long term patient outcomes in ARM patients. TYPE OF STUDY Retrospective Comparative Study. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Erin M Garvey
- Phoenix Children's Hospital, 1919 E. Thomas Road, Phoenix, AZ, 85106, USA
| | - Megan Fuller
- Boys Town National Research Hospital, 14040 Boys Town Hospital Rd, Omaha, NE, 68010, USA
| | | | - Casey M Calkins
- Children's Hospital of Wisconsin, 999 N. 92nd Street, Milwaukee, WI, 53226, USA
| | - Rebecca M Rentea
- Children's Mercy Kansas City, University of Missouri- Kansas City, Kansas City, MO, 64108, USA
| | - Matthew Ralls
- C.S. Mott Children's Michigan University of Michigan, 1540 E. Hospital Drive, Ann Arbor, MI, 48109, USA
| | - Richard Wood
- Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Michael D Rollins
- Primary Children's Hospital, University of Utah, 100 N. Mario Capecchi Drive, Salt Lake City, UT, 84113, USA
| | - Jeffrey Avansino
- Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
| | - Ron W Reeder
- Data Coordinating Center, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Megan M Durham
- Division of Pediatric Surgery, Emory University School of Medicine and Children's Healthcare of Atlanta, 1405 Clifton Road NE, 3rd Floor, Tower 1, Pediatric Surgical Suite, Atlanta, GA, 30322, USA.
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Fanjul M, Samuk I, Bagolan P, Leva E, Sloots C, Giné C, Aminoff D, Midrio P. Tethered cord in patients affected by anorectal malformations: a survey from the ARM-Net Consortium. Pediatr Surg Int 2017; 33:849-854. [PMID: 28674920 DOI: 10.1007/s00383-017-4105-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/30/2017] [Indexed: 11/27/2022]
Abstract
PURPOSE The goal of this study was to determine the degree of consensus in the management of spinal cord tethering (TC) in patients with anorectal malformation (ARM) in a large cohort of European pediatric centers. METHODS A survey was sent to pediatric surgeons (one per center) members of the ARM-Net Consortium. RESULTS Twenty-four (86%) from ten different countries completed the survey. Overall prevalence of TC was: 21% unknown, 46% below 15, and 29% between 15 and 30%. Ninety-six agreed on screening all patients for TC regardless the type of ARM and 79% start screening at birth. Responses varied in TC definition and diagnostic tools. Fifty percent of respondents prefer ultrasound (US), 21% indicate either US or magnetic resonance (MRI) based on a pre-defined risk of presenting TC, and 21% perform both. Discrepancy exists in complementary test: 82% carry out urodynamic studies (UDS) and only 37% perform somatosensory-evoked potentials (SSEP). Prophylactic untethering is performed in only two centers (8%). CONCLUSIONS Survey results support TC screening in all patients with ARM and conservative management of TC. There is discrepancy in the definition of TC, screening tools, and complementary test. Protocols should be developed to avoid such variability in management.
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Affiliation(s)
- María Fanjul
- Department of Pediatric Surgery, Gregorio Marañón University General Hospital, Calle del Dr. Esquerdo, 46, 28007, Madrid, Spain.
| | - I Samuk
- Department of Pediatric Surgery, Schneider Children's Medical Center of Israel, Sackler Medical School, University of Tel Aviv, Tel Aviv, Israel
| | - P Bagolan
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, Rome, Italy
| | - E Leva
- Department of Pediatric Surgery, Fondazione Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - C Sloots
- Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - C Giné
- Department of Pediatric Surgery, Vall d'Hebron Hospital, Barcelona, Spain
| | - D Aminoff
- Italian Association for Anorectal Malformations, Rome, Italy
| | - P Midrio
- Mother and Child Department-Section of Pediatric Surgery, Cá Foncello Hospital, Treviso, Italy
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Kyrklund K, Pakarinen MP, Taskinen S, Kivisaari R, Rintala RJ. Spinal cord anomalies in patients with anorectal malformations without severe sacral abnormalities or meningomyelocele: outcomes after expectant, conservative management. J Neurosurg Spine 2016; 25:782-789. [PMID: 27448173 DOI: 10.3171/2016.4.spine1641] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The goal of this study was to determine the significance of spinal cord anomalies (SCAs) in patients with anorectal malformations (ARMs) by comparing the outcomes for bowel function, lower urinary tract symptoms (LUTS), and lower-limb neurological abnormalities to these outcomes in patients with similar ARMs and a normal spinal cord. METHODS The spinal cord MRI records of female patients treated for vestibular and perineal fistula (VF/PF) and male patients with rectourethral fistula (RUF) at a single center between 1983 and 2006 were reviewed. Bowel function and LUTS were assessed by questionnaire. Patients with extensive sacral anomalies or meningomyelocele were excluded. RESULTS Of 89 patients (median age 15 years, range 5-29 years), MRI was available in 90% (n = 80; 40 male patients with RUF), and 80% of patients returned the questionnaire (n = 64; 31 male patients with RUF). Spinal cord anomalies were found in 34%, comprising a filum terminale lipoma in 30%, low conus medullaris in 10%, and thoracolumbar syrinx in 6%. Bowel functional outcomes between patients with SCAs (n = 23) and those with a normal spinal cord (n = 41) were not significantly different for soiling (70% vs 63%), fecal accidents (43% vs 34%), and constipation (57% vs 39%; p = not significant for all). The LUTS, including urge (65% vs 54%), urge incontinence (39% vs 24%), stress incontinence (17% vs 22%), and straining (32% vs 29%) were also comparable between groups (p = not significant for all). No patients developed lower-limb neurological abnormalities. CONCLUSIONS The results suggest that the long-term functional outcomes for patients with SCAs who had VF/PF and RUF may not differ significantly from patients with the same type of ARMs and a normal spinal cord. The results favor a conservative approach to their management in the absence of abnormal neurological findings in the lower limbs.
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Affiliation(s)
- Kristiina Kyrklund
- Department of Pediatric Surgery, University of Helsinki, Hospital for Children and Adolescents, Helsinki, Finland
| | - Mikko P Pakarinen
- Department of Pediatric Surgery, University of Helsinki, Hospital for Children and Adolescents, Helsinki, Finland
| | - Seppo Taskinen
- Department of Pediatric Surgery, University of Helsinki, Hospital for Children and Adolescents, Helsinki, Finland
| | - Reetta Kivisaari
- Department of Pediatric Surgery, University of Helsinki, Hospital for Children and Adolescents, Helsinki, Finland
| | - Risto J Rintala
- Department of Pediatric Surgery, University of Helsinki, Hospital for Children and Adolescents, Helsinki, Finland
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Midrio P, Mosiello G, Ausili E, Gamba P, Marte A, Lombardi L, Iacobelli BD, Caponcelli E, Marrello S, Meroni M, Brisighelli G, Leva E, Rendeli C. Peristeen(®) transanal irrigation in paediatric patients with anorectal malformations and spinal cord lesions: a multicentre Italian study. Colorectal Dis 2016; 18:86-93. [PMID: 26304756 DOI: 10.1111/codi.13101] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 05/29/2015] [Indexed: 02/08/2023]
Abstract
AIM In paediatric and adult patients with neurogenic bowel, transanal irrigation (TAI) of the colon has gained popularity due to the introduction of a specifically designed device. The aim of this pilot study was to present the results of TAI using the Peristeen(®) TAI system in a group of paediatric patients with anorectal malformation (ARM) and congenital or acquired spinal cord lesions (SCLs). METHOD Eight Italian paediatric surgery and spina bifida centres participated in the study. The inclusion criteria were age between 6 and 17 years, weight above 20 kg and unsatisfactory bowel management. Patients with chronic inflammatory bowel disease, mental disability and surgery within the previous 3 months were excluded. At the beginning of treatment (T0) and after 3 months (T1) the Bristol scale, a questionnaire assessing bowel function, and two questionnaires on quality of life (QoL) for patients aged 6-11 years (CHQ-pf50) and 12-17 years (SF36) were administered. RESULTS Eighty-three patients were enrolled, and seventy-eight completed the study (41 ARMs, 37 SCLs). At T1, constipation was reduced in ARMs from 69% to 25.6% and in SCLs from 92.7% to 41.5%, faecal incontinence in ARMs from 50% to 18.6% and in SCLs from 39% to 9.8% and flatus incontinence in ARMs from 20.9% to 9.8% and in SCLs from 31.7% to 10%. At T0, the Bristol Stool Scale types were 1-2 in 45% of ARMs and 77.5% of SCL patients, whereas at T1 types 1-2 were recorded in only 2.5% of SCL patients. QoL improved in both groups. In the younger group, a significant improvement in QoL was recorded in ARM patients for eight of nine variables and in SCL patients for seven of nine variables. CONCLUSION This study showed that Peristeen TAI resulted in a significant time reduction in colonic cleansing, increased independence from the carer and improved QoL in paediatric patients with ARMs and SCLs.
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Affiliation(s)
- P Midrio
- Pediatric Surgery Unit, Department of Woman and Child Health, University Hospital, Padua, Italy
| | - G Mosiello
- Neuro-Urology Unit/Spina Bifida Center and Department of Medical and Surgical Neonatology, Bambino Gesù Children Hospital and Research Institute, Rome, Italy
| | - E Ausili
- Spina Bifida Center, Department of Paediatric Science, Catholic University Medical School, Rome, Italy
| | - P Gamba
- Pediatric Surgery Unit, Department of Woman and Child Health, University Hospital, Padua, Italy
| | - A Marte
- Pediatric Surgery Unit, Second University of Naples, Naples, Italy
| | - L Lombardi
- Pediatric Surgery Unit, Pediatric Hospital, Parma, Italy
| | - B D Iacobelli
- Neuro-Urology Unit/Spina Bifida Center and Department of Medical and Surgical Neonatology, Bambino Gesù Children Hospital and Research Institute, Rome, Italy
| | - E Caponcelli
- Pediatric Surgery Unit, Vittore Buzzi Pediatric Hospital, Milan, Italy
| | - S Marrello
- Pediatric Surgery Unit, Annunziata Hospital, Cosenza, Italy
| | - M Meroni
- Pediatric Surgery Unit, Vittore Buzzi Pediatric Hospital, Milan, Italy
| | - G Brisighelli
- Department of Pediatric Surgery, Fondazione Ca'Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - E Leva
- Department of Pediatric Surgery, Fondazione Ca'Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - C Rendeli
- Spina Bifida Center, Department of Paediatric Science, Catholic University Medical School, Rome, Italy
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Impact of spinal dysraphism on urinary and faecal prognosis in 25 cases of cloacal malformation. J Pediatr Urol 2014; 10:1199-205. [PMID: 25113956 DOI: 10.1016/j.jpurol.2014.05.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Accepted: 05/13/2014] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Urinary and faecal continence are key challenges goal of cloacal malformation management. Most well-known prognostic factors are the length of common channel (CC) and the presence of a sacral defect, but the impact of associated spinal dysraphism is less well documented. The aim of this study was to investigate the impact of different types of dysraphism on urinary and faecal continence in this patient population. MATERIALS AND METHODS From 1991 to 2011, charts and office notes of 25 patients with cloacal malformation were retrospectively reviewed. At last clinic visit, urinary and faecal continence status according to Krickenbeck criteria were correlated with the length of CC, the presence of a sacral defect (sacral ratio), and the presence of different types of spinal cord dysraphism using magnetic resonance imaging (MRI) and Fisher's exact test. RESULTS Mean follow-up was 8 years (4 months-21 years). The sacral ratio was abnormal (below 0.74) in 18 cases out of 25 (72%). MRI review showed normal spinal cord in eight out of 23 cases (Group 1), spinal cord anomaly in 15 out of 23 cases (65%) including nine cases of tethered cord complex (Group 2) and six cases of a short spinal cord (Group 3). While statistical analysis showed a difference regarding urinary prognosis between the groups (p=0.005), no significant difference was found regarding faecal prognosis. None of the six patients with short spinal cord were continent for both urinary and faecal prognosis. CONCLUSIONS This is the first study, which highlights the impact of different types of spinal dysraphism on functional outcome in patients with cloaca. Short spinal cord seemed to carry the worst prognosis. A prospective study with a larger series is mandatory to confirm these preliminary results.
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Arnoldi R, Macchini F, Gentilino V, Farris G, Morandi A, Brisighelli G, Leva E. Anorectal malformations with good prognosis: variables affecting the functional outcome. J Pediatr Surg 2014; 49:1232-6. [PMID: 25092082 DOI: 10.1016/j.jpedsurg.2014.01.051] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Revised: 12/20/2013] [Accepted: 01/15/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND/PURPOSE The purpose of this study was to investigate the outcome of patients operated for anorectal malformations (ARMs) with good prognosis. METHODS Thirty patients underwent clinical evaluation by Rintala score and anorectal manometry recording anal resting pressure (ARP), rectoanal inhibitory reflex (RAIR), and rectal volume (RV). The results were analysed with regard to sex, type of ARM, surgical timing of posterior sagittal anorectoplasty (PSARP), neurospinal cord dysraphism (ND), neonatal colostomy, and institution where they underwent surgery. RESULTS 6/30 (20%) presented ND despite normal sacrum. 17/30 (57%) patients had a normal Rintala score. ND and neonatal colostomy were significantly associated with a pathologic score (p=0.0029 and p=0.0016). Patients with ND had significantly lower ARP compared to patients with normal spine (23.5±7.2mmHg vs 32±7.9mmHg, p=0.023). ARP was significantly lower in patients with neonatal colostomy compared to patients with primary repair (25.22±10.24mmHg vs 32.57±6.68mmHg, p=0.026). RAIR was present in only 2/6 (33%) patients with ND, while in 21/24 (87.5%) without ND (p=0.015) and in 4/9 (44%) patients with neonatal colostomy, while in 19/21 (90.5%) patients submitted to primary repair (p=0.014). CONCLUSIONS Neurospinal cord dysraphism may be present despite normal sacral ratio. From a clinical point of view, patients with good prognosis ARMs are not completely comparable to healthy children. Neurospinal cord dysraphism and neonatal colostomy seem to worsen the clinical and manometric (ARP and RAIR) outcomes of these patients.
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Affiliation(s)
- Rossella Arnoldi
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milano, Italy.
| | - Francesco Macchini
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milano, Italy
| | - Valerio Gentilino
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milano, Italy
| | - Giorgio Farris
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milano, Italy
| | - Anna Morandi
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milano, Italy
| | - Giulia Brisighelli
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milano, Italy
| | - Ernesto Leva
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milano, Italy
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Nah SA, Ong CCP, Lakshmi NK, Yap TL, Jacobsen AS, Low Y. Anomalies associated with anorectal malformations according to the Krickenbeck anatomic classification. J Pediatr Surg 2012; 47:2273-8. [PMID: 23217888 DOI: 10.1016/j.jpedsurg.2012.09.017] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Accepted: 09/01/2012] [Indexed: 12/11/2022]
Abstract
PURPOSE We evaluated the incidence of congenital anomalies associated with anorectal malformations (ARMs) in relation to the anatomic type of ARM as defined by the Krickenbeck classification. METHODS We reviewed 99 children with ARM in our institution from 2002 to 2011. Data were collected on patient demographics, type of ARM, and associated congenital anomalies, which were categorized according to organ systems. Statistical analysis was performed for comparison between groups using 'perineal fistula' as the base group. RESULTS There were 62 (63%) male patients. The majority had perineal fistulas (35, 35%). Seventy-seven (78%) had at least one associated malformation. The most frequent malformations seen were genitourinary (28, 28%) and spinal anomalies (26, 26%). Those with rectovesical fistula had the highest proportion of genitourinary malformations (Odds Ratio [OR], 41.3; 95% confidence interval [CI], 4.7-363.4). Those with cloaca (OR, 49.5; 95% CI, 3.4-718.9) and those with rectovestibular fistula (OR, 12.4; 95% CI, 2.3-65.6) were most likely to have major spinal abnormalities, with tethered cord seen in all groups. The rectovestibular group was also most likely to have other associated malformations (OR, 8.6; 95% CI, 2.2-32.8). CONCLUSION More than 75% of children with anorectal malformation have other associated malformations. Genitourinary anomalies are the most common. Major spinal anomalies are seen in all groups, affecting nearly half of those with rectovestibular fistula and those without fistula. The incidence of associated malformations in the rectovestibular group is higher than described in the literature. Thorough systematic evaluation of all infants with ARM should be done regardless of type of ARM.
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Affiliation(s)
- Shireen A Nah
- Department of Paediatric Surgery, KK Women's & Children's Hospital, Singapore 229899, Singapore
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Pescatori M. Fecal Incontinence. PREVENTION AND TREATMENT OF COMPLICATIONS IN PROCTOLOGICAL SURGERY 2012:165-182. [DOI: 10.1007/978-88-470-2077-1_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Letter to the Editor regarding the article "Anorectal malformations and neurospinal dysraphism: is this association a major risk for continence?". Pediatr Surg Int 2011; 27:549-50. [PMID: 21400032 DOI: 10.1007/s00383-011-2875-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/23/2011] [Indexed: 10/18/2022]
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Pescatori M. Incontinenza fecale. PREVENZIONE E TRATTAMENTO DELLE COMPLICANZE IN CHIRURGIA PROCTOLOGICA 2011:165-183. [DOI: 10.1007/978-88-470-2062-7_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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