Critical analysis of fecal incontinence scores

Perioperative Histologically Controlled Fistula Resection in Patients with Imperforate Anus and Perineal Fistula

INTRODUCTION

 Postoperative constipation (PC) in patients with imperforate anus and perineal fistula (PF) has been reported in up to 60%. Histological studies of PF revealed innervation anomalies which seem to be one of the reasons for PC. Perioperative histologically controlled fistula resection (PHCFR) allows appropriate resection of PF and pull-down normoganglionic rectum at the time of posterior sagittal anorectoplasty (PSARP).

MATERIALS AND METHODS

 A total of 665 patients with anorectal malformations underwent surgery between 1991 and 2021. Of these, 364 presented PF; 92 out of them (41 F) were studied. Patients with sacral and spinal cord anomalies, neurological disorders, and cut-back anoplasty were excluded. PSARP was done on all patients. Hematoxylin-eosin staining and NADH Tetrazolium-reductase histochemical method were used. Four and more ganglion cells in the myenteric plexus represented a sufficient length of the resection. The continence was scored according to the modified Krickenbeck scoring system. Final scores ranged from 1 to 7 points. Values are given as median.

RESULTS

 A total of 65 (70.7%) patients presented an aganglionic segment in PF, and 27 patients presented hypoganglionosis. The median length of the resected fistula was 25 mm (interquartile range [IQR]: 20-30). The median total continence score was 7 (IQR: 6-7). Post-op constipation was observed in 6/92 (6.5%) patients.

CONCLUSION

 PHCFR diminished PC to 6.5% of patients.

A Systematic Review of Telehealth Utilization for Bowel Management Programs in Pediatric Colorectal Surgery

Recent advancements in pediatric surgery have embraced telehealth (TH) modalities, transitioning from traditional in-person consultations to virtual care. This shift has broadened access to healthcare, potentially enhancing affordability, patient and caregiver satisfaction, and clinical outcomes. In pediatric colorectal surgery, telehealth has been effectively utilized to support Bowel Management Programs (BMPs) for children suffering from constipation and fecal incontinence. A systematic review was conducted to assess the effectiveness of virtual BMPs, analyzing studies from January 2010 to December 2023, sourced from MEDLINE (via PubMed), Embase, and the Cochrane Library, with five studies included. Remote BMPs, implemented through video or telephone consultations, reported satisfaction rates exceeding 75% among families, indicating a strong preference for virtual interactions over traditional visits. Significant findings from the studies include improvements in Vancouver and Baylor scores, reductions in the duration of multidisciplinary consultations, enhancements in pediatric quality of life and Cleveland scores, and decreased frequency of laxative treatments. The implementation of TH has facilitated patient-led care, enabling timely adjustments in treatment and efficient distribution of medical supplies. The findings suggest that virtual BMPs are a viable and effective alternative to conventional approaches, yielding high caregiver satisfaction and superior clinical outcomes while promoting patient independence.

Laparoscopic-assisted distal colon excision and proximal colon pull-through anorectoplasty for anorectal malformation

Purpose

During the second stage surgery for anorectal malformations (ARM), patients whose distal intestine of the colostomy is particularly short underwent laparoscopic-assisted distal colon excision and proximal colon pull-through anorectoplasty (PCPARP). This study aimed to discuss the outcomes of PCPARP after colostomy in patients with ARM.

Methods

This is a single-center propensity score-matched (PSM) study which was retrospectively initiated patients with intermediate- or high-type ARM who underwent laparoscopic surgery from June 2007 to December 2018. These patients were divided into PCPARP group and conventional laparoscopic-assisted anorectoplasty (LAARP) group according to specific surgical methods. The general data, surgical data, postoperative complications, and functional results were evaluated.

Results

In total, 216 patients were included in this study: 190 (88.0%) undergoing LAARP approach and 26 (12.0%) undergoing PCPARP approach. After PSM, two well-balanced groups of 26 patients were analyzed and showed the postoperative complications (P = 0.126) and bowel function (P = 0.809) were similiar between the two groups.

Conclusions

The curative effect of PCPARP after colostomy is similar to that of classic LAARP surgery, which can be used for ARM patients with a very short and abnormal distal intestine of the stoma.

Functional outcome of Hirschsprung's disease in children: A single center study at The Children's Hospital Lahore

AIM

Hirschsprung's disease (HD) is a congenital bowel disorder resulting in functional dysmotility. Advancement in surgical techniques has improved outcomes, but recent studies have identified problems having significant impact on patient's quality of life. The aim of this study is to analyze postoperative functional outcome after definitive surgery for Hirschsprung's disease.

METHOD

A retrospective study was conducted at the Department of Pediatric Surgery, The Children's Hospital Lahore. The record of 64 patients was reviewed from the year 2009 to 2019. Parents were interviewed on phone calls and a predesigned questionnaire was filled. Degree of constipation, incontinence and voluntary bowel movements was analyzed according to Krickenbeck classification.

RESULTS

Median age at initial presentation was 11 days, with male to female ratio of 3.9:1. Most common presentation was delayed passage of meconium (38%). Diagnosis was made on biopsy in 70.3%, but contrast enema and biopsy in 29.7%. Aganglionosis was limited to short segment in 81.3% and long segment in 14.5%. Decompressing enterostomy was made in 63% at a mean age of 191 days. Definitive surgery included Duhamel pull-through in 89.1%. Mean age at follow-up was 10.6 ± 4.19 years and alive patients were 95.4%. Postoperative enterocolitis was reported by 27%, while 35.5% reported fecal incontinence and 16.1% complained of constipation. 80% could voluntarily hold bowel movement, among which 5% had a feeling of urge and 15% had the capacity to verbalize. In 25% of the patients, fecal incontinence was a constant social problem and in 25% of these patients constipation was resistant to diet and laxatives.

CONCLUSION

On long-term follow-up, fecal incontinence was more worrisome, affecting quality of life and requiring help of the bowel management program. Such patients need close follow-up after definitive procedure, so that they have normal stooling habits in their adulthood and lead a normal life.

Diagnostic capabilities of transperineal ultrasound (TPUS) to evaluate anal sphincter defect post obstetric anal sphincter injury (OASIS)? A systematic review

INTRODUCTION

Endoanal ultrasound (3D-EAUS) is the gold standard imaging investigation for evaluating the anal sphincter; unfortunately, it is not universally available in most obstetric units. This study aims to appraise the ability of transperineal ultrasound (TPUS) compared with 3D-EAUS as the gold standard to identify anal sphincter defects after primary repair of OASIS.

METHODS

A systematic search of major databases to identify diagnostic accuracy of 3D-TPUS in evaluating anal sphincter defects. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were designed for this systematic review. The risk of bias and applicability concerns were assessed using the QUADAS-2 tool. Our eligibility criteria are patients with a history of primary repair of anal sphincter injuries (OASIS). They were followed up after the primary repair to detect the anal sphincter defect using 3D-TPUS vs. 3D-EAUS as a gold standard.

RESULTS

Two eligible observational studies were included and assessed for risk of bias using the QUADAS-2 tool and showed a low risk of bias and a low risk of concerns. 3D-TPUS had various sensitivity to detect external anal sphincter defects in two studies; meanwhile, the specificity was around 67-70%. For detecting the internal anal sphincter defects, 3D-TPUS had low sensitivity but high specificity (93-94%).

CONCLUSION

3D-TPUS had various sensitivity to detect external anal sphincter defects and low sensitivity to detect internal anal sphincter defects. On the other hand, 3D-TPUS had low specificity for detecting external anal sphincter defects and high specificity for detecting internal anal sphincter defects.

One-stage versus staged laparoscopic-assisted anorectoplasty for high-and intermediate anorectal malformations: Medium-term outcomes from a propensity score matching analysis

BACKGROUND

The timing of anorectoplasty for anorectal malformations (ARMs) is controversial and essential for long-term bowel function. The advantages of laparoscopy make primary anoplasty possible for neonates. This study aims to report the medium-term results of the one-stage laparoscopic-assisted anorectoplasty (LAARP) and compare them with the staged LAARP.

METHODS

This study included 242 boys who underwent LAARP between June 2013 and December 2018 in our center. Forty-five neonatal patients successfully underwent the one-stage LAARP, and the remaining 197 patients who had already undergone colostomy received staged procedures. The complications and bowel function were compared between the two groups after 1:1 propensity score matching (PSM).

RESULTS

Before matching, age at assessment and classification were significantly different between the two groups (P < 0.05). After PSM, 42 patients were included in each of the two groups, and the patients were well balanced. The overall occurrence of postoperative complications in the one-stage group was significantly lower than in the staged group (P < 0.05). The median follow-up periods were 55.0 and 54.5 months, respectively. The mean value of BFS was similar in the two groups. After medical management, a second evaluation was conducted to distinguish overflow pseudo-incontinence from patients with no bowel control potential. The functional outcome in the two groups is comparable (P = 0.307).

CONCLUSIONS

One-stage LAARP is safe and feasible for neonates with high-and intermediate-type ARMs. Compared with staged LAARP, one-stage LAARP has fewer complications and comparable functional outcomes. The authors recommend these procedures to be performed in dedicated centers with sufficient expertise.

LEVEL OF EVIDENCE

Level III.

Diagnosis and management of fecal incontinence in children and adolescents

Fecal incontinence (FI) is a commonly occurring disease of high concern. It is characterized by voluntary and involuntary defecation in children and adolescents. It is not only a physical disease but also a psychological and behavioral disorder. FI poses a serious burden on individuals and their families and therefore has become a social problem. Unfortunately, the management of FI among children is still a challenge because the etiology varies widely. Constipation has been found to be the most common cause, while sphincter dysfunction and neurogenic abnormalities may also play a role. Currently, no consensus guidelines exist, and the criteria for selecting optional methods remain unclear. It is therefore necessary to improve the efficacy of diagnosis and management strategies of FI in children. This review focused on the classification and etiology, discussed the diagnosis and management methods of FI in children and adolescents, and aimed to guide future studies.

Laparoscopic-Assisted Anorectoplasty for Rectovestibular Fistula: A Comparison Study with Anterior Sagittal Anorectoplasty

BACKGROUND

 Posterior or anterior sagittal anorectoplasty (ASARP) is the mainstream for correcting rectovestibular fistula (RVF). However, the intermediate RVF has the potential risk of wound complications when applying ASARP due to its high rectal pouch, long fistula tract, and difficulty separating the rectum and vagina. We developed laparoscopic-assisted anorectoplasty (LAARP) for surgical correction of RVF, which has acceptable preliminary outcomes. The purpose of this study is to evaluate the safety and efficacy of LAARP in comparison with ASARP for patients with RVF.

MATERIALS AND METHODS

 Twenty-five patients with RVF who underwent LAARP between October 2017 and December 2020 were retrospectively reviewed. The outcomes were compared with 43 patients who underwent ASARP between April 2015 and August 2018. The age, weight at operation, sacral ratio, operative time, and postoperative hospital stay were evaluated. The results were assessed for complications, perineum appearance, and bowel function.

RESULTS

 The two groups were comparable in terms of demographics. The median operative time of the LAARP group was significantly longer than that of the ASARP group (113 vs. 95 minutes; p = 0.015). The mean length of the resected rectum in the LAARP group was also longer than that in the ASARP group (6.75 ± 5.07 vs. 3.31 ± 3.06 cm; p = 0.001). Compared with the LAARP group, complications in the ASARP group were more frequent (4.0 vs. 27.9%, p = 0.036). No intraoperative or postoperative wound-related complications occurred in the LAARP group. However, in the ASARP group, one patient had an intraoperative vaginal injury and four had postoperative anastomosis-related complications. The incidence of redo operation in the ASARP group was significantly higher than that in the LAARP group (p = 0.000). Cosmetic satisfaction was higher in the LAARP group (96.0 vs. 76.7%; p < 0.05). In terms of voluntary bowel movement, soiling, and constipation, the LAARP group had similar results compare with the ASARP group.

CONCLUSION

 The LAARP technique has shown several unique strengths in treating intermediate type RVF, including lower risks of complications, and minimal muscular injury, with a comparable bowel function.

Low muscle volume of the anal sphincter complex: A novel prognostic factor in children with anorectal malformations?

BACKGROUND/PURPOSE

The anal sphincter complex (ASC) plays a key role in continence and is often dysfunctional in infants born with anorectal malformations (ARM). The ASC is well depicted by magnetic resonance (MR) imaging but volumetric reference data are lacking in infants. Thus, we tested the feasibility of MR based ASC volumetry, collected reference data, and compared them with cases of favorableprognosis and unfavorable prognosis (as defined by the type of ARM).

METHODS

We determined ASC volume on T2 weighted MR images of seventy six infants (ARM n = 33; controls n = 43) by manual segmentation. Inter operator agreement was assessed by intraclass correlation coefficient. Linear regression was used to establish weight dependent reference data. Observed to expected ASC volumes of patients with unfavorable and favorable prognosis were compared (unpaired t test).

RESULTS

ASC volumetry was feasible in all cases. Patients with ARM had low 'observed to expected' ASC volume ( 18.1%; p = 0.006). 'Observed to expected' ASC volume differed significantly between patients with favorableand unfavorable prognosis (p < 0.001).

CONCLUSION

We confirmed the feasibility of MRI based ASC volumetry and provided initial reference data for infants. Although ASC volumes were lowest in infants with ARM of unfavorable prognosis for fecal continence, the value of ASC volume as prognostic parameter remains to be determined.

Long-Term Functional Outcomes of an Anorectal Malformation French National Cohort

OBJECTIVES

The present study aimed to assess long-term functional outcomes of children with anorectal malformations (ARMs) across a network of expert centers in France.

METHODS

Retrospective cross-sectional study of patients ages 6-30 years that had been surgically treated for ARM. Patient and ARM characteristics (eg, level, surgical approach) and functional outcomes were assessed in the different age groups.

RESULTS

Among 367 patients, there were 155 females (42.2%) and 212 males (57.8%), 188 (51.2%) cases with, and 179 (48.8%) higher forms without, perineal fistula. Univariate and multivariate statistical analyses with logistic regression showed correlation between the level of the rectal blind pouch and voluntary bowel movements (odds ratio [OR] = 1.84 [1.31-2.57], P < 0.001), or soiling (OR = 1.72 [1.31-2.25], P < 0.001), which was also associated with the inability to discriminate between stool and gas (OR = 2.45 [1.28-4.67], P = 0.007) and the presence of constipation (OR = 2.97 [1.74-5.08], P < 0.001). Risk factors for constipation were sacral abnormalities [OR = 2.26 [1.23-4.25], P = 0.01) and surgical procedures without an abdominal approach (OR = 2.98 [1.29-6.87], P = 0.01). Only the holding of voluntary bowel movements and soiling rates improved with age.

CONCLUSION

This cross-sectional study confirms a strong association between anatomical status and functional outcomes in patients surgically treated for ARM. It specifically highlights the need for long-term follow-up of all patients to help them with supportive care.

Development of a Bowel Management Scoring Tool in Pediatric Patients with Constipation

OBJECTIVE

To develop a reliable and valid scoring tool, the Pediatric Bowel Management Scoring Tool (PBMST), to better guide management of constipation in pediatric patients.

STUDY DESIGN

The project comprised 2 stages, development of the questionnaire and construction of the bowel management score. Two questionnaires were created, one for children aged 8-18 years to self-report and one parent proxy-report for children aged 4-8 years. Questions regarding physical symptoms (n = 6), emotional aspects (n = 2), social activities/school (n = 1), and treatment (n = 1) were included. Patients (or parents of patients) with symptoms of constipation completed the questionnaire. The reproducibility of each question was computed using the Cohen weighted kappa coefficient (κ). A bowel management score was developed using logistic regression analysis, assessing the associations between the questions and impact on self-reported quality of life (QoL). Questions with adequate reproducibility and significantly associated with QoL were incorporated into the score.

RESULTS

The questionnaire was completed by 385 patients. Six questions met the inclusion criteria and were incorporated into the score: stool shape (range, 0-3 points), anorectal pain (0-4 points), abdominal pain (0-3 points), frequency of fecal incontinence (0-3 points), assistance of caregivers (0-3 points), and interference with social activities (0-6 points). Differences in bowel management scores among patients reporting no, little, some, or major impact on QoL were statistically significant (P < .001).

CONCLUSIONS

The newly developed and validated PBMST is a reliable tool for evaluating bowel management strategies in children with constipation.

Prospective quality of life outcomes in pediatric fecal incontinence following bowel management

BACKGROUND

Severe fecal incontinence (FI) is common in patients both with and without anorectal malformations. Whether a formal bowel management program (BMP) has significant effects on FI, psychosocial development of the child, and caregiver stress is poorly understood. We hypothesize that BMP participation results in long-term clinical and quality of life (QOL) improvements for patients and caregivers.

METHODS

Using a prospective cohort study over three years, 342 children (age 3-12 years) and caregivers were followed for one year after attending a week-long BMP, during which a regimen was tailored to promote daily stool evacuation.FI QOL was measured with the validated Cincinnati Fecal Incontinence Scale (CINCY-FIS), evaluating multiple subscales, including parental stress. Scores were obtained at multiple timepoints following BMP (baseline, 2 weeks, 3 months, 1 year).

RESULTS

Within 2 weeks, BMP participation significantly improved FI with increased frequency of daily daytime voluntary bowel movements (20%-70%, p < 0.001) and decreased daily daytime and nighttimeinvoluntary bowel movements (60%-20%, p < 0.001; 30%-10%, p < 0.05). Marked improvements in CINCY-FIS were observed across multiple QOL subscales, with the greatest in parental stress, and sustained through one year.

CONCLUSIONS

BMP results in significant and sustained improvement in FI and QOL for patients and caregivers.

Long-Term Results of One-Stage Laparoscopic-Assisted Endorectal Pull-Through for Rectosigmoid Hirschsprung's Disease in Patients Aged Above 5 Years

Purpose: Despite the fact that the laparoscopic-assisted endorectal pull-through (LAEPT) for Hirschsprung's disease (HD) was introduced over 20 years ago, published outcomes in older children and adolescent are lacking. To address this, we studied the long-term results of LATEP for rectosigmoid HD in patients above 5 years of age. Materials and Methods: A retrospective review was conducted on all nonsyndromic patients above 5 years of age and who underwent one-stage LAEPT for rectosigmoid HD between January 2002 and December 2017. Late Hirschsprung-associated enterocolitis (HAEC) was defined as HAEC occurring 1 year after the pull-through operation. Postoperative bowel function was assessed using the Krickenbeck classification. Results: Forty-one patients (37 males and 4 females) were included in this study with a median follow-up of 9.0 years. The median age at surgery was 55 days. Two patients had anastomotic leakage. No patient had late HAEC, rectal prolapse, anastomotic stricture, or intestinal obstruction. According to the Krickenbeck classification, all patients had voluntary bowel movements without constipation. Overall, 65.8% of patients had no soiling. However, on subgroup analysis, only 45.4% of patients younger than 11 years of age had no soiling compared with 89.5% in patients at or older than 11 years of age (P = .003). Conclusions: Our results showed that LAEPT for rectosigmoid HD was a safe procedure. Nearly 90% of patients had normal bowel function by puberty. Further studies are needed to address the problem of soiling in patients younger than 11 years of age.

Bowel function after transanal endorectal pull-through for Hirschsprung disease - does outcome improve over time?

BACKGROUND

The reported functional outcome in patients operated with transanal endorectal pull-through (ERPT) for Hirschsprung disease (HD) varies greatly. Some studies suggest better functional outcome in older than in younger HD patients, but there are almost no longitudinal studies that have demonstrated such improvement. Therefore, we aimed to compare functional outcome in a cohort of HD patients over time to assess whether bowel function improves with increasing age.

METHODS

Functional outcome in HD patients operated with ERPT from 1998 to 2007 was recorded by standardized interviews by an independent investigator during 2008-2011 and again in 2017/2018. Bowel function was assessed using the Krickenbeck questionnaire. Clinical data were collected prospectively.

RESULTS

50 of the original 62 patients responded for a second interview. Median age at the two interviews was 8,1 (3,4-16,6) and 15,4 (9,9-25) years respectively. There was no difference in the rate of soiling at first (52%) and second (52%) follow-up. Constipation was reported in 20% of the patients at first, and in 24% at second follow-up. Bowel management was used by 30% and 32% at first and second interview respectively.

CONCLUSION

Soiling and constipation are common in HD patients several years after surgery, and no improvement of bowel function with increasing age could be demonstrated.

LEVEL OF EVIDENCE

Level II.

Treatment of megarectum in anorectal malformation with emphasis on preventive aspects: 17 years experience

PURPOSE

Megarectum in anorectal malformation (ARM) causes severe morbidity. To compare conservative management (CM) of megarectum with excision (EX), to propose a new classification and to analyse management strategies.

METHODS

Between 2000-2016, we reviewed all ARM to identify megarectum, defined by radiological recto-pelvic ratio > 0.61. A new classification was proposed: primary megarectum (PM) pre-anorectoplasty, and secondary megarectum (SM) post-anorectoplasty, with sub-types. Complications and Krickenbeck bowel function were compared between CM and EX.

RESULTS

Of 124 ARM, 22 (18%) developed megarectum; of these, 7 underwent EX. There was no difference in functional outcomes when comparing CM vs EX-voluntary bowel movement (both 86%), soiling (40% vs. 57%) and constipation (both 86%). However, EX was associated with major complications (43%) and the requirement for invasive bowel management, compared to CM (85% vs. 27%, P = 0.02). 6/7 EX needed antegrade continence enema (ACE), one of these has a permanent ileostomy. With strategic changes, incidence of megarectum reduced from 20/77 (26%) to 2/47 (4%) after 2013 (P = 0.002).

CONCLUSION

EX did not confer benefit in the functional outcome but carried a high risk of complications, often needing ACE or stoma. By adhering to strategies discussed, we reduced the incidence of megarectum and have avoided EX since 2013.

Same-Day Discharge and Quality of Life for Primary Laparoscopic Rectopexy for Rectal Prolapse in Children: A 10-Year Experience

Introduction: Rectal prolapse (RP) in pediatric patients may require surgical intervention. Varying surgical approaches and heterogenous patient populations have resulted in difficulty defining surgical outcomes and superiority of technique. We sought to review our surgical and self-reported outcomes of patients who underwent laparoscopic rectopexy for idiopathic RP. Methods: Records of children <18 years who underwent primary laparoscopic rectopexy between March 2009 and March 2019 were retrospectively reviewed. Patients with redo rectopexy were excluded. Demographics, pre- and postoperative treatment, and outcome data were collected and reported using descriptive statistics. Qualitative analysis of a quality of life (QoL) questionnaire administered to patients and parents 2-10 years postoperatively was performed. Results: Fifteen patients were included. Median age at surgery was 5 years (interquartile range [IQR] 3, 12.5); 60% were male and median weight was 22 kg (IQR 16.4, 39.2). Median length of stay was 6 hours (IQR 4, 22) with 9 (60%) discharged the same day. Perioperatively, 73% were on laxative for constipation, whereas only 33% were on laxative therapy at 6 months postrectopexy. Median follow-up was 19 months (IQR 8, 39). Three patients (20%) suffered recurrent RP (2 required redo rectopexy), and 2 patients self-limited urinary retention. Respondents to the QoL questionnaire indicated improvement in symptoms after surgery. No patient reported fecal incontinence, smearing, or leakage of stool. Conclusion: Laparoscopic rectopexy is a safe minimally invasive approach for children with idiopathic RP that offers high patient satisfaction with same-day discharge, early recovery, and low recurrence.

Does clinical score accurately support fecoflowmetry as a means to assess anorectal motor activity in pediatric patients after anorectal surgery?

PURPOSE

We investigated the relationship between Krickenbeck score (KS) and fecoflowmetry (FFM) parameters and assessed the characteristics of this new questionnaire test by comparing Kelly's clinical score (KCS) in pediatric patients with anorectal surgery for anorectal malformation (ARM) and Hirschsprung's disease (HD).

METHODS

We enrolled pediatric patients who underwent anorectal surgery for ARM or HD. Bowel function was assessed with KS and KCS thereafter, FFM and anorectal manometry (AM) were conducted. Patients were divided into subgroups according to each parameter of the scoring system and each FFM parameter was compared among the KCS or KS subgroups, respectively. Moreover, correlation analyses were conducted between FFM and AM parameters.

RESULTS

The comparison of FFM parameters among the subgroups of KCS showed that F_max in the KCS staining 2 group was significantly higher than that in KCS staining 1 group and the F_max in KCS sphincter squeeze 1 group was significantly higher than that in KCS sphincter squeeze 0 group. Moreover, F_max in the KCS "good" group was significantly higher than that in the KCS "fair" group. The comparison of FFM parameters among the subgroups of KS parameters showed that TR in the no soiling group was significantly higher than that in the KS grade 2 soiling group. FFM and AM parameters showed a significant positive correlation between F_max and voluntary squeezing anal pressure.

CONCLUSION

FFM clarified the different characteristics of two scoring systems, namely, KCS reflects the anal sphincter performance, whereas the KS soiling score might reflect the tolerance and evacuation ability.

Neurostimulation-guided Anal Intrasphincteric Botulinum Toxin Injection in Children With Hirschsprung Disease

OBJECTIVES

In Hirschsprung disease (HD), despite successful surgical treatment, 50% of children experience long-term functional gastrointestinal problems, particularly chronic functional obstructive symptoms. We report our experience regarding clinical effects of neurostimulation-guided anal intrasphincteric botulinum toxin (BT) injections on postoperative obstructive symptoms attributed to a nonrelaxing anal sphincter complex in HD patients.

METHODS

In this monocenter cohort study, 15 HD patients with postoperative functional intestinal obstructive symptoms received neurostimulation-guided anal intrasphincteric BT injections. Short-, medium-, and long-term effects were evaluated. The Bristol stool form scale was used to assess stool consistency, and the Jorge-Wexner (JW) score to assess fecal continence.

RESULTS

The median age at first injection was 4 years. In the short-term, a significant improvement in stool consistency was noted in 12 of 14 patients (P = 0.0001) and JW score decreased for 14 of 15 patients (P = 0.001). In the medium-term, JW score significantly decreased for all patients (P = 0.0001), with an improvement of 50% or more for 10 patients (66.7%). In the long term, 83.3% of patients had normal stool consistency and JW score was <3 for all. Recurrent enterocolitis decreased from 86.7% to 8.3%. A complete resolution of all symptoms without further medication was observed in 66.7% of patients in the long term.

CONCLUSIONS

Intrasphincteric BT injection was a safe, effective, and durable option for the management of postoperative functional intestinal obstructive symptoms in HD. The use of neurostimulator guidance for specific delivery of BT to muscular fibers of nonrelaxing anal sphincter complex takes into consideration the variability of patient's anatomy secondary to curative surgery.

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.