Biopsychosocial treatment of defecation problems in children with anal atresia: a retrospective study

[Adaptation and quality of life in anorectal malformation: empirical findings, theoretical concept, Psychometric assessment, and cognitive-behavioral intervention]

Anorectal malformations are inborn developmental defects that are associated with multiple functional Impairments (especially incontinence) and psychosocial burden with a major impact on body schema and self-esteem. Child psychology and psychiatry research begin to identify disorder-dependent and -independent risk and protective factors that predict the outcome of psychological adaptation and quality of life. The present paper analyses the interference of structural and functional disease parameters with the achievement of regular developmental tasks, presents a hypothetical conceptual framework concerning the development of psychological adaptation and quality of life in ARM, integrates findings from empirical research with the framework presented and outlines strategies of psychological support from a cognitive-behavioural perspective within a multidisciplinary treatment approach to enhance medical, functional, and psychosocial quality of life.

Prospective evaluation of comorbidity and psychosocial need in children and adolescents with anorectal malformations. Part 2: evaluation of psychosocial need

PURPOSE

Only a few patients with anorectal malformations (ARM) have satisfactory bowel functions. Studies of ARM have reported psychosocial problems in up to 73% of patients. The aim of the current study was to document the psychosocial needs of patients with ARM.

METHODS

Between June 2004 and September 2005, 44 patients with ARM were treated; the sample included 30 patients (23 males and 7 females) aged 4-17. To focus on potential psychosocial strain, a comprehensive grading system with a sophisticated perspective of continence, associated malformations, number of surgical interventions and postoperative complications was introduced. For psychosocial screening, the following instruments were used: German "Basis-Dokumentation" (BADO), Impact on Family Scale (IFS), the Strengths and Difficulties Questionnaire (SDQ). All families assessed their own psychosocial needs. An extensive psychosocial programme was provided.

RESULTS

Twenty-three patients were suffering severe burden according to the comprehensive grading system. Nearly half of the families reported increased financial stress, and one-third reported emotional or hyperactivity problems of the child. More than 70% confirmed psychosocial need.

CONCLUSIONS

Paediatric surgeons should promote psychosocial support for all patients who suffer severe forms of ARM or its numerous associated malformations as well as for patients undergoing numerous surgical interventions or having many postoperative complications.

Prospective evaluation of comorbidity and psychosocial need in children and adolescents with anorectal malformation. Part one: paediatric surgical evaluation and treatment of defecating disorder

INTRODUCTION

Anorectal malformations represent a continuing challenge for the paediatric surgeon. Faecal and urinary incontinence can occur even with an excellent anatomic repair. We undertook a prospective evaluation of comorbidity and psychosocial needs in children and adolescents with anorectal malformation to test the hypothesis whether psychosocial workup in concert with an improved continence situation would lead to a better functional outcome in patients suffering from defecating disorders. Treatment of defecating disorder was based on differentiation between overflow pseudo-incontinence and true faecal incontinence.

MATERIALS AND METHODS

Patients who presented with soiling regardless of the type of anomaly were included in the study: 44 patients were investigated, 14 patients did not meet the criteria of the study, 30 patients aged 4-18 were evaluated. The surgical diagnostic program comprised a careful clinical history, physical examination, exact classification of the malformation, evaluation for associated defects, stool protocol.

RESULTS

Patients were grouped in two different management programs according to their continence situation. Patients with pseudo-incontinence were treated with enemas, diet, anal hygiene, behavioural therapy and physiotherapy. Patients with true faecal incontinence were included in a bowel management program: 28 patients were free of symptoms of soiling after 3 days of hospital treatment and remained free of symptoms 6 months and 1 year later at re-evaluation. Two patients did not follow the therapeutic regime and therefore did not show an improved condition concerning soiling in the long run.

CONCLUSION

Differentiating between overflow pseudo-incontinence and true faecal incontinence is the basis of an effective treatment of defecating disorders. All patients born with anorectal malformation can be kept clean of stool if they are subjected to an adequate treatment. A multidisciplinary approach is a valuable supplement to standard therapy.

Multidisciplinary behavioural treatment of fecal incontinence and constipation after correction of anorectal malformation

BACKGROUND

Fecal incontinence and constipation are major problems after correction of anorectal malformation (ARM), caused not only by the somatic defects but also by a psychosomatic dysfunction of defecation. To better release patients from this dysfunction we offered a multidisciplinary, psycho- and physiotherapeutic therapy according to an approach developed in Nijmegen (Netherlands). We herein summarize the preliminary results to evaluate whether the approach can be adopted with similar success.

METHODS

Since January 2002 multidisciplinary behavioural treatment (MBT) has been offered to children above 3 years of age and suffering from fecal incontinence and constipation after surgical correction of ARM in our department or elsewhere. Prerequisites included no anal stenosis, regulation of stool consistency, and a suitable defecation diary over 2 weeks. MBT contained regular consultations by a pediatric psychologist and a physiotherapist, teaching the child to establish a regular defecation pattern and how to push while relaxing the pelvic floor. The entry- and post-treatment situation was prospectively monitored by means of defecation and constipation scoring systems.

RESULTS

Complete data were available in 10 patients (9 males, 1 female) with high (8 patients) and low (2) forms of anal atresia initially, who finished MBT 2-36 months ago (mean: 13 months). The average amount of stool reaching the toilet was 27% before and 90% after therapy. Clean days were absent before, reaching 3.7 days on average after therapy. Constipation was present in 6 patients before (3 of them on enemas) and in 2 after therapy (no enemas needed). The duration of MBT was 7 months on average, range 3-23 months, with 8-9 sessions per patient, each lasting 60-90 minutes. An observation period of 7 months after treatment confirmed stable results. MBT turned out to improve body-consciousness and self-confidence.

CONCLUSIONS

MBT is effective in reducing incontinence and constipation in patients after ARM. It helps the children and their families to relieve psychosocial stress. The approach can be successfully adopted, if a team of committed specialists is available and sufficient compliance of patients and families is given.

Follow-up of anorectal anomalies: the Italian parents' and patients' perspective

BACKGROUND

Several studies addressed the long-term follow-up of anorectal anomalies (ARM) in relation to clinical issues (eg, continence) and quality of life. However, most of these studies are based upon questionnaires designed by physicians and/or health-care professionals, which may be sources of bias.

METHODS

To investigate whether parents of children (patients themselves or older children or adults) who were born with ARM had the perception that they received appropriate care and follow-up, a survey was carried out in Italy, in 2003, among families with children with ARM. A 20-item questionnaire was mailed to 425 patients and parents listed in the AIMAR (Italian association for anorectal malformation) database and was returned by 209 families. The questionnaire covered different aspects of ARM: type of malformations and surgery, associated anomalies, fecal and urinary continence, as well as aspects about information given to the parents and satisfaction of care and follow-up received.

RESULT

The patients and parents demonstrated a good understanding of distribution of malformations and their anatomical classification; nevertheless, 67% of responders had to travel outside their living area for surgery. Bowel management (BM) was commonly used among subjects; however, a significant percentage of patients using regular enemas were still soiling (58 patients were clean and 116 soiled). Urinary continence problems were mostly found in females with cloaca; nevertheless, 21 male patients reported occasional dribbling of difficult interpretation. Most subjects were provided with a good explanation about their or their child's malformation at time of reconstructive surgery, but the same level of information was missing about functional prognosis later in life when the need of an appropriate psychologic support was also felt.

CONCLUSIONS

Patients and parents born with ARM are generally satisfied with the information received and with the short-term postreconstructive follow-up care. At longer follow-up, although more than a quarter of patients are completely clean, there is a significant percentage of subjects who still soil while following a BM program. This is explained by the small number of nurses and BM specialists who are involved in the rehabilitation process and by the lack of appropriate information about functional prognosis that are conveyed to the parents. In this respect, psychologic support in bridging the gap between cure and care may be critical.

Anorectal malformations: does healthcare meet the needs?

OBJECTIVES

The first aim was to identify the types of healthcare services used by children, adolescents, and adults with anorectal malformation (ARM) in relation to the severity of their disease and to examine whether additional care was needed. The second aim was to evaluate specific areas in the healthcare system, including provided information, transfer from pediatric to adult care, and satisfaction with the provided care.

METHODS

Three hundred eighty-six (61%) patients with ARM, ages 6 to 52, completed a questionnaire that assessed their use of healthcare services and the need for additional services. Also, questions were asked about specific areas in the healthcare system. Clinical and sociodemographic characteristics were extracted from medical records.

RESULTS

In the preceding 6 months 50% of the children, 24% of the adolescents, and 24% of the adults consulted a medical specialist. Compared with patients with a mild form of ARM in the age range of 6 to 16 years, the more severely afflicted patients visited medical professionals more often (18% vs. 32%). Particularly, adolescents in the age range of 12 to 16 years with a severe form of the disease more often visited the pediatric surgeon than their peers with a mild form (2% vs. 16%). Twenty-three percent of the children, 7% of the adolescents, and 8% of the adults consulted a nonmedical professional. Twenty percent of the children, 13% of the adolescents, and 17% of the adults would have liked additional or more treatment of a nonmedical professional. In 6 months, 40% of the children, 24% of the adolescents, and 20% of the adults received treatment information. One third of the adult patients who were transferred to "adult" surgeons encountered transfer problems. Almost all patients were satisfied with the care provided.

CONCLUSIONS

There is good access to medical healthcare services, especially for children. However, more psychosocial and paramedical care is considered necessary. As could be expected, children and adolescents with a severe form of the disease reported to have visited a medical specialist more often. Although healthcare for patients with ARM may be improved at certain points, most parents and patients were very satisfied with the care provided.

Dynamic graciloplasty in patients born with an anorectal malformation

PURPOSE

The aim of this study was to compare long-term results for patients born with an anorectal malformation and fecal incontinence treated with a dynamic graciloplasty with those for the total group of patients undergoing dynamic graciloplasty.

METHODS

Consecutive patients with fecal incontinence after surgical treatment of anorectal malformation and treated with dynamic graciloplasty were included in this study. Preoperative assessment was performed. Postoperative follow-up consisted of anorectal manometry and registration of defecation frequency, continence scores, and postponement time of defecation.

RESULTS

Twenty-eight patients with a median age of 25.5 years were included in the study. The median follow-up was 4 years. A high anorectal malformation was present in 89.3 percent of patients. Conventional graciloplasty had been previously performed in 36 percent. All patients were incontinent for stools. Median frequency of defecation was four times/day. Median postponement time of defecation was 0 minutes. Rectoanal inhibition reflex was present in 17 percent of patients. Median preoperative sensory threshold during balloon distention was 30 ml and median maximum urge threshold was 165 ml. Satisfactory continence was reached in 35 percent of patients, however, 7.1 percent of patients gained this continence score by additional bowel irrigation. Twenty-nine percent of patients were incontinent for loose stool, 36 percent were incontinent for formed stool. Satisfactory continence was achieved in only 18 percent of patients with a high anorectal malformation, compared with 100 percent in patients with a low anorectal malformation. In the total group of patients with dynamic graciloplasty, satisfactory continence was obtained in 76 percent. The sensitivity threshold in patients with a successful dynamic graciloplasty was lower than that in patients with a failing dynamic graciloplasty (45 vs. 24 ml, P = 0,06). When we compare median preoperative rectal sensitivity threshold in our study group with that in the total patient group with dynamic graciloplasty, statistical difference was established (P = 0.008). Postponement time (0 to 20 minutes) and anal squeeze pressure (81 to 120 mmHg) increased significantly after surgery. Patients with an anorectal malformation had significantly lower resting and stimulation pressure than that of the total group of patients, but the difference between resting and stimulation pressure in both groups was not significantly different (P = 0.33). The difference between resting and stimulation pressure was not significantly different between anorectal malformation patients with a failing dynamic graciloplasty and patients with a successful dynamic graciloplasty. Complications were noted in 57 percent of patients. Explantation of the dynamic graciloplasty was necessary in 32 percent of patients, mainly because of infection of the implant.

CONCLUSIONS

Results of dynamic graciloplasty for fecal incontinence are reasonable for this specific group of patients with limited treatment options. Despite functional dynamic graciloplasty, the results are worse than those for the total group of patients with dynamic graciloplasty. Rectal sensitivity and type of malformation are prognostic factors for outcome and can be used to select patients for treatment with dynamic graciloplasty, thereby improving treatment outcome.

Multidisciplinary behavioral treatment of defecation problems: a controlled study in children with anorectal malformations

BACKGROUND/PURPOSE

The most frequent consequences of being born with an anorectal malformation (ARM) are problems with fecal continence and constipation, which can have various negative implications. In this prospective, controlled study the effect of multidisciplinary behavioral treatment dealing with these problems is evaluated.

METHODS

The effect of multidisciplinary behavioral treatment was studied in 24 children (15 boys, 9 girls; mean age 5.8 years). Thirteen children were allocated to the treatment condition. The 11 children allocated to the waiting list control group also were treated after a waiting period of 6 months. Children underwent follow-up after treatment.

RESULTS

Compared with a waiting list control group, the experimental treatment group scores significantly better on 2 important measures ("Templeton," "Percentage of feces in toilet"). Although young children had poorer scores than older children before treatment, no significant differences in the favorable outcome of treatment were found between both groups after treatment. No effect of type of ARM on treatment was found either. The results of multidisciplinary behavioral treatment remain stable over a mean follow-up period of 7 months.

CONCLUSION

Multidisciplinary behavioral treatment is an important and valuable supplement to the standard medical treatment of children born with ARM suffering from chronic defecation problems.