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Máslová D, Holubová Z, Poš L, Newland N, Pavlíková M, Škába R, Kynčl M. The comparison of magnetic resonance and fluoroscopic imaging options in the preoperative assessment of boys with anorectal malformations and a colostomy. Pediatr Radiol 2024; 54:68-81. [PMID: 38038736 DOI: 10.1007/s00247-023-05816-1] [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: 07/05/2023] [Revised: 11/09/2023] [Accepted: 11/10/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND In recent decades, magnetic resonance imaging (MRI) has gained prominence as a standard diagnostic method for preoperative assessment in patients with anorectal malformations and a colostomy, with the potential to replace the classic fluoroscopic distal pressure colostogram (FDPC). Three MRI techniques are available: MRI-distal pressure colostogram with gadolinium (MRI-DPCG) or saline (MRI-DPCS) instillation into the colostomy and native MRI without colostomy instillation. OBJECTIVE To evaluate and compare the diagnostic accuracy of MRI (native MRI, MRI-DPCG and MRI-DPCS) in the preoperative workup of boys with an anorectal malformation and a colostomy and to compare it to FDPC. MATERIALS AND METHODS Sixty-two boys with preoperative MRI using one of the three approaches and 43 with FDPC met the inclusion criteria for this retrospective study. The presence and localization of rectal fistulas according to the Krickenbeck classification were evaluated and compared with intraoperative findings. RESULTS The accuracy of fistula detection for MRI in general (regardless of the technique), MRI-DPCS, MRI-DPCG, native MRI and FDPC was 95% (59/62, P<0.001), 100% (12/12, P=0.03), 100% (30/30, P<0.001), 85% (17/20, P=0.41) and 72% (31/43, P=0.82), respectively. The accuracy of describing fistula type in patients with a correctly detected fistula using these methods was 96% (45/47, P<0.001), 100% (9/9, P<0.001), 100% (23/23, P<0.001), 87% (13/15, P<0.001) and 67% (13/21, P=0.002), respectively. CONCLUSION MRI is a reliable method for detecting and classifying fistulas in boys with an anorectal malformation and a colostomy and can be considered the modality of first choice for preoperative workup.
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Affiliation(s)
- Darja Máslová
- Department of Radiology, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, V Úvalu 84, 15006, Prague, Czech Republic.
| | - Zuzana Holubová
- Department of Radiology, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, V Úvalu 84, 15006, Prague, Czech Republic
| | - Lucie Poš
- Department of Paediatric Surgery, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Natália Newland
- Department of Paediatric Surgery, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Markéta Pavlíková
- Department of Probability and Mathematical Statistics, Faculty of Mathematics and Physics, Charles University in Prague, Prague, Czech Republic
| | - Richard Škába
- Department of Paediatric Surgery, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Martin Kynčl
- Department of Radiology, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, V Úvalu 84, 15006, Prague, Czech Republic
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Caruso AM, Bommarito D, Girgenti V, Amato G, Calabrese U, Figuccia A, Baldanza F, Grasso F, Giglione E, Casuccio A, Milazzo MPM, Di Pace MR. Evaluation of Anal Sphincter with High Resolution Anorectal Manometry and 3D Reconstruction in Patients with Anorectal Malformation. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1037. [PMID: 37371268 DOI: 10.3390/children10061037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 05/27/2023] [Accepted: 06/01/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND Patients with anorectal malformation (ARM) need long-term follow-up, in order to evaluate fecal continence; the main predictors of longer-term success are the type of ARM, associated anomalies and sacral integrity. Three-Dimensional High Resolution Anorectal Manometry (3D-HRAM) gives detailed information on pressure on the anal complex profile. Our objective was to analyze anal sphincter activity in ARM patients with 3D-HRAM establishing the correlation between manometric and clinical data. METHODS Forty ARM patients were submitted to 3D-HRAM: manometric, anatomical and clinical scores were correlated with each other and with the bowel management response (BM). RESULTS A positive correlation between all scores and types of ARM was found: in high ARM and in patients with spinal anomalies (regardless to ARM type) lower scores were reported and even after BM they did not achieve good continence. CONCLUSIONS 3D-HRAM gives detailed data on the functional activity of the anal sphincter complex. Our study revealed a correlation between manometric parameters and clinical outcomes, confirming spinal malformations and ARM type as the most important prognostic risk factors for a bad outcome. Specific sphincteric defects can also be explored with manometry, allowing for tailored bowel management strategies.
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Affiliation(s)
- Anna Maria Caruso
- Pediatric Surgical Unit, Children's Hospital 'G. di Cristina', ARNAS Civico, 90100 Palermo, Italy
| | - Denisia Bommarito
- Pediatric Surgical Unit, Children's Hospital 'G. di Cristina', ARNAS Civico, 90100 Palermo, Italy
| | - Vincenza Girgenti
- Pediatric Surgical Unit, Children's Hospital 'G. di Cristina', ARNAS Civico, 90100 Palermo, Italy
| | - Glenda Amato
- Pediatric Surgical Unit, Children's Hospital 'G. di Cristina', ARNAS Civico, 90100 Palermo, Italy
| | - Ugo Calabrese
- Pediatric Surgical Unit, Children's Hospital 'G. di Cristina', ARNAS Civico, 90100 Palermo, Italy
| | - Adele Figuccia
- Pediatric Surgical Unit, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialities, University of Palermo, 90100 Palermo, Italy
| | - Fabio Baldanza
- Pediatric Surgical Unit, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialities, University of Palermo, 90100 Palermo, Italy
| | - Francesco Grasso
- Pediatric Surgical Unit, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialities, University of Palermo, 90100 Palermo, Italy
| | - Emanuela Giglione
- Pediatric Surgery Division, Women's and Children's Health Department, University of Padua, 35100 Padua, Italy
| | - Alessandra Casuccio
- Pediatric Surgical Unit, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialities, University of Palermo, 90100 Palermo, Italy
| | | | - Maria Rita Di Pace
- Pediatric Surgical Unit, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialities, University of Palermo, 90100 Palermo, Italy
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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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Harris KT, Wilcox DT. Management of the urological tract in children with anorectal malformations - a contemporary review. Ther Adv Urol 2023; 15:17562872231161468. [PMID: 36969498 PMCID: PMC10034273 DOI: 10.1177/17562872231161468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 02/16/2023] [Indexed: 03/29/2023] Open
Abstract
Anorectal malformations (ARMs) consist of a broad spectrum of congenital anomalies that are associated with an equally wide variety of urological abnormalities, often with increasing incidence as the severity of the ARM increases. The importance of urologic involvement in the care of ARM patients has been noted for decades and is critical from birth to adulthood. Urology must be involved in the initial evaluation and operative care of the child as well as in monitoring and managing issues such as neurogenic bladder, renal disease, and eventually sexual function and fertility. Care of the ARM patient must be done through a multidisciplinary lens, with the urologist as a key player. This review will serve as an update on the management of the urologic tract in children with ARM.
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Affiliation(s)
| | - Duncan T. Wilcox
- Division of Urology, Department of Surgery,
Children’s Hospital Colorado, University of Colorado Anschutz Medical
Campus, Aurora, CO, USA
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5
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Uy MNAR, Tantengco OAG. Investigating the landscape and trajectory of spina bifida research in Asia: a bibliometric analysis. Childs Nerv Syst 2022; 38:1581-1591. [PMID: 35474541 DOI: 10.1007/s00381-022-05527-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 04/10/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Spina bifida is a type of a neural tube defect which affects 243.14 per 100,000 babies in Asia. Research articles on spina bifida have increased in the recent years. However, no study has focused on the research trends in this field in Asia. METHODS A systematic review of literature on spina bifida in Asia was performed using the Scopus database from inception to 2020. All published studies on spina bifida conducted in or published by authors from Asia were included in our analysis. Bibliometric information was obtained from Scopus and bibliometrics diagrams were created using VOSviewer software. RESULTS A total of 652 articles were obtained in this study. The number of publications showed an upward trend starting 2000s. The country with the greatest number of publications was Japan while All India Institute of Medical Sciences was the most productive institution in spina bifida research in Asia. The current focus of this field in Asia was prevalence of spina bifida, prenatal diagnosis, folic acid supplementation, and complications of spina bifida. Future areas of research in spina bifida include the genetic basis of neural tube defects and the use of stem cell technology as therapies for spina bifida. CONCLUSION This is the first bibliometric analysis on spina bifida in Asia. It showed the trend and future areas of research on spina bifida in Asia. Despite the increase in scientific literature on spina bifida research, more research outputs and collaborations are needed especially in developing countries in Asia.
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Affiliation(s)
| | - Ourlad Alzeus G Tantengco
- College of Medicine, University of the Philippines Manila, Pedro Gil Street, Ermita, Manila, Philippines.
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6
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Risk factor analysis of irreversible renal dysfunction based on fetal ultrasonographic findings in patients with persistent cloaca: Results from a nationwide survey in Japan. J Pediatr Surg 2022; 57:229-234. [PMID: 34809962 DOI: 10.1016/j.jpedsurg.2021.10.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 10/23/2021] [Indexed: 12/14/2022]
Abstract
AIM OF THE STUDY We conducted a nationwide survey of persistent cloaca (PC) to determine its current status in Japan. We focused on the relationship between fetal ultrasonographic findings and irreversible renal dysfunction in PC. METHOD Patient information was obtained via questionnaire, and 466 PC patients were ultimately enrolled in this study. Fifteen patients (3.2%) who required dialysis or kidney transplantation were compared to those who were able to survive with their native kidney. Univariable and multivariable analyses were performed using a logistic regression analysis to clarify the relationship between irreversible renal dysfunction and fetal ultrasonographic findings. RESULTS A multivariable logistic analysis showed that fetal ultrasonic findings of oligohydramnios independently increased the risk of irreversible renal dysfunction (adjusted odds ratio [OR] 5.8, 95% confidence interval [CI] 1.7-20, p = 0.005). A regression analysis showed that fetal ultrasonographic findings of hydroureteronephrosis (crude OR 5.6, 95% CI 0.9-24, p = 0.03) tended to be associated with irreversible renal dysfunction. In the PC patients with oligohydramnios, however, the ultrasonographic findings and associated anomalies did not affect the renal prognosis. The 15 renal dysfunction patients were treated as follows: hemodialysis (n = 4), peritoneal dialysis (n = 3), living donor renal transplantation (n = 8), and cadaveric renal transplantation (n = 1). CONCLUSION Fetal ultrasonographic findings of oligohydramnios increase the risk of irreversible renal dysfunction. Such findings suggest we consider the need for earlier therapeutic intervention, such as fetal and postnatal treatment, to prevent the progression of renal dysfunction. LEVEL OF EVIDENCE III (Study of diagnostic test, study of nonconsecutive patients and/or without a universally applied "gold" standard).
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Versteegh HP, Gardner DS, Scriven L, Martens L, Kluivers K, Hewitt G, de Blaauw I, Wood RJ, Williams A, Sutcliffe J. Reconsidering Diagnosis, Treatment, and Postoperative Care in Children with Cloacal Malformations. J Pediatr Adolesc Gynecol 2021; 34:773-779. [PMID: 34419606 DOI: 10.1016/j.jpag.2021.08.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/07/2021] [Indexed: 12/25/2022]
Abstract
Cloacal malformations are among the most complex types of anorectal malformation and are characterized by the urological, genital, and intestinal tracts opening through a single common channel in the perineum. Long-term outcome is affected by multiple factors, which include anatomical variants of the malformation itself, associated anomalies, and the surgical approach. Reconsidering these variables and their influence on "patient important" function might lead to strategies that are more outcome-driven than focused on the creation of normal anatomy. Key outcomes reflect function in each of the involved tracts and the follow-up needed should therefore not only include the classical fields of colorectal surgery and urology but also focus on items such as gynecology, sexuality, family-building, and quality of life as well as other psychological aspects. Involving patients and families in determining optimal treatment strategies and outcome measures could lead to improved outcomes for the individual patient. A strategy to support delivery of personalized care for patients with cloacal malformations by aiming to define the best functional outcomes achievable for any individual, then select the treatment pathway most likely deliver that, with the minimum morbidity and cost, would be attractive. Combining the current therapies with ongoing technological advances such as tissue expansion might be a way to achieve this.
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Affiliation(s)
- Hendt P Versteegh
- Department of Pediatric Surgery, Erasmus Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - David S Gardner
- School of Veterinary Medicine and Science, University of Nottingham, Sutton Bonington Campus, Nottingham, United Kingdom
| | - Lucy Scriven
- School of Veterinary Medicine and Science, University of Nottingham, Sutton Bonington Campus, Nottingham, United Kingdom
| | - Lisanne Martens
- Department of Gynecology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Kirsten Kluivers
- Department of Gynecology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Geri Hewitt
- Department of Pediatric and Adolescent Gynecology, Nationwide Children's Hospital, Columbus, Ohio
| | - Ivo de Blaauw
- Department of Pediatric Surgery, Radboud University Medical Center, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Richard J Wood
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Alun Williams
- Departments of Paediatric Surgery and Urology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Jonathan Sutcliffe
- Department of Paediatric Surgery, Leeds Teaching Hospitals NHS Trust, The General Infirmary at Leeds, Leeds, United Kingdom
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Esposito G, Totonelli G, Morini F, Contini G, Palma P, Mosiello G, Longo D, Schingo PM, Marras CE, Bagolan P, Iacobelli BD. Predictive value of spinal bone anomalies for spinal cord abnormalities in patients with anorectal malformations. J Pediatr Surg 2021; 56:1803-1810. [PMID: 34167803 DOI: 10.1016/j.jpedsurg.2021.05.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 05/07/2021] [Accepted: 05/11/2021] [Indexed: 10/01/2022]
Abstract
AIM To evaluate the correlation between sacral/vertebral anomalies and spinal cord anomalies (SCA) on MRI, in patients with anorectal malformation (ARM). METHODS Patients with ARM consecutively treated between January 1999 and August 2019 were included. Radiological imaging of sacrum and spine were retrospectively analyzed and correlated to the presence of SCA at MRI. Fisher's exact test and X2 test were used as appropriate; p<0.05 was considered statistically significant. RESULTS 348 patients with ARM were enrolled in the study, 147 presented SCA at MRI. 144 patients showed spinal bone anomalies, isolated vertebral and sacral anomalies were found in 17,6% and 35% respectively. Higher level of ARM was associated with a significant higher prevalence of sacral and vertebral anomalies. A significant correlation was found between the "level" of ARM and the presence of SCA (p<0.05). Sacral anomalies were significantly correlated with the presence of SCA at MRI (p<0.05). SCA were found in 70% of patients with vertebral anomalies (VA) and in 76% of patients with sacral anomalies. The presence of multiple malformations (vertebral and sacral anomalies) are strictly related to the presence of SCA. However, the absence of spinal bone anomalies does not exclude the presence of SCA. SD was the most represented type of SCA (n=94/147), of those 96% had fatty filum. Neurological or neurourological symptoms were detected in 11,5% patients (n=17) with SCA and required neurosurgical intervention. CONCLUSIONS Our data confirm the strong relation between sacral or vertebral anomalies and SCA. However, in our series also patients without sacral/vertebral anomalies had SCA at MRI. Our results suggest that, despite the presence or absence of spinal anomalies, spinal cord MRI should be performed in all children with ARM, to allow a correct multidisciplinary follow-up and treatment. In fact, most patients with spinal bone and SCA are asymptomatic, but could develop clinical manifestations during their growth.
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Affiliation(s)
- Giacomo Esposito
- Department of Neuroscience, Neurosurgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Giorgia Totonelli
- Medical and Surgical Department of the Fetus-Newborn-Infant, Newborn Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Francesco Morini
- Medical and Surgical Department of the Fetus-Newborn-Infant, Newborn Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Giorgia Contini
- Medical and Surgical Department of the Fetus-Newborn-Infant, Newborn Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Paolo Palma
- Department of Neuroscience, Neurosurgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Giovanni Mosiello
- Department of Surgery, Neuro-Urology Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Daniela Longo
- Neuroradiology Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | | | - Carlo Efisio Marras
- Department of Neuroscience, Neurosurgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Pietro Bagolan
- Medical and Surgical Department of the Fetus-Newborn-Infant, Newborn Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy; Department of System Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Barbara Daniela Iacobelli
- Medical and Surgical Department of the Fetus-Newborn-Infant, Newborn Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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Long-term urological assessment and management of cloaca patients: A single tertiary institution experience. J Pediatr Surg 2021; 56:984-987. [PMID: 32778449 DOI: 10.1016/j.jpedsurg.2020.07.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/09/2020] [Accepted: 07/09/2020] [Indexed: 11/22/2022]
Abstract
PURPOSE Preserving renal function and achieving urinary continence are the most important urological goals in the management of cloaca patients. Many prognostic factors have been described, such as the length of the common channel (CC) and urethra, the presence of spinal dysraphism, and associated urological anomalies. The aim of this study was to analyze urinary continence status and need for reconstructive procedures and their correlation with urological risk factors in a series with a long-term follow-up. MATERIAL AND METHODS The institutional database of patients with anorectal malformations was reviewed. Patients with cloaca who underwent cloacal reconstructive surgery at our institution between January 1995 and May 2015 and who had a minimum postoperative follow-up of 5 years with complete urological care were included. Urologic and spinal anomalies, length of the CC, renal function, urodynamic study patterns, continence status, and urologic reconstructive surgeries were assessed. A CC was defined as long CC when its measure was longer than 3 cm in the cloacogram and then confirmed by cystoscopy. Descriptive statistical analysis was performed. RESULTS Fifty-five cloaca patients with a mean follow-up of 12 years (5-20) were included. A long CC was documented in 38 patients (69%). The sacral ratio (SR) was <0.4 in the AP projection in 30 (54.5%). Urodynamic evaluation revealed an inadequate detrusor contraction pattern in 65.4% of the cases. A CC >3 cm and SR <0.4 were significantly correlated with this urodynamic finding. A total of 50 patients (91%) achieved urinary continence, but only 30.9% had volitional voiding and 56% needed major urological reconstructive surgeries. Eighteen patients (32.7%) were in stage 2 or more of chronic kidney disease (<90 ml/min/1.73 m2) at the last follow-up visit. CONCLUSION Cloacal management requires a multidisciplinary and long-term follow-up. Early assessment of prognostic urological factors and accurate stratification of each patient are essential to avoid renal impairment and achieve urinary continence in the future. The length of the common channel and the presence of spinal dysraphism were correlated with the presence of neurovesical dysfunction specifically an abnormal bladder contraction efficiency. A significant number of these patients will need catheterization and reconstructive urinary tract surgeries to attain urinary continence. TYPE OF STUDY Retrospective study. LEVEL OF EVIDENCE Level 3. Retrospective comparative study.
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Yang Z, Jia H, Bai Y, Wang W. Spatiotemporal expression of neurogenic locus notch homolog protein 1 in developing caudal spinal cord of fetuses with anorectal malformations from ETU-fed rats. J Mol Histol 2020; 51:519-530. [PMID: 32783102 DOI: 10.1007/s10735-020-09900-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 07/25/2020] [Indexed: 10/23/2022]
Abstract
Complications, such as fecal soiling, incontinence, and constipation, are major health issues for patients with anorectal malformations (ARMs) after surgery. Dysplasia of the caudal spinal cord is an increasingly pivotal area in the field of postoperative complications for patients with ARMs. However, the existing research has not fully defined the mechanism underlying ARMs development. The neurogenic locus notch homolog (Notch) signaling pathway comprises several highly conserved proteins that are involved in spinal cord developmental processes. In the present study, the emerging role of Notch1 in fetal lumbosacral spinal cords was investigated in a rat model of ARMs using ethylene thiourea. Immunohistochemical staining, western blot and quantitative reverse transcription real-time polymerase chain reaction were utilized to analyze spatiotemporal expression of Notch1 on embryonic days (E) 16, E17, E19, and E21. The expression levels of the neuronal marker neurofilament and recombination signal-binding protein-J protein were evaluated for temporal correlations to Notch1 expression. The results implied that Notch1 expression was reduced in lumbosacral spinal cord neurons of ARMs embryos compared to control embryos. These results showed that, in ARMs embryos decreased Notch1 expression is related to the dysplasia of the caudal spinal cord during embryogenesis, indicating that Notch signaling may participate pathogenic embryonic lumbosacral spinal development and may be associated with postoperative complications of ARMs.
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Affiliation(s)
- Zhonghua Yang
- Department of Pediatric Surgery, Shengjing Hospital of China Medical University, Weilin Wang. 36, Sanhao Street, Heping District, Shenyang, 110004, Liaoning, China
| | - Huimin Jia
- Department of Pediatric Surgery, Shengjing Hospital of China Medical University, Weilin Wang. 36, Sanhao Street, Heping District, Shenyang, 110004, Liaoning, China
| | - Yuzuo Bai
- Department of Pediatric Surgery, Shengjing Hospital of China Medical University, Weilin Wang. 36, Sanhao Street, Heping District, Shenyang, 110004, Liaoning, China
| | - Weilin Wang
- Department of Pediatric Surgery, Shengjing Hospital of China Medical University, Weilin Wang. 36, Sanhao Street, Heping District, Shenyang, 110004, Liaoning, China.
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Jehangir S, Adams S, Ong T, Wu C, Goetti R, Fowler A, Sannappa Venkatraman S. Spinal cord anomalies in children with anorectal malformations: Ultrasound is a good screening test. J Pediatr Surg 2020; 55:1286-1291. [PMID: 31708202 DOI: 10.1016/j.jpedsurg.2019.09.077] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 09/20/2019] [Accepted: 09/30/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE The purpose of this study is to correlate spinal ultrasound (US) and magnetic resonance imaging (MRI) findings in patients with anorectal malformations (ARMs). METHODS A retrospective analysis of records was performed for children with ARM presenting to two major pediatric hospitals between 2009 and 2017. The primary outcome analyzed was detection of spinal cord anomalies. Spinal US was performed up to 4 months and MRI within the first year of life. The conus medullaris was considered normal if it had a tapering contour and terminated at or above the Lumbar 2-3 disk space. RESULTS One hundred ninety-three patients with ARM presented during the study period with a slight male preponderance (108, 56%). Spinal imaging was performed in 157(82%) - 137(87%) had US, 64(41%) had MRI and 44 (28%) had both. Of the 44 who had both; US was abnormal in 25 children-confirmed by MRI in 20 (80%). US was normal in 17 children- MRI showed a filum cyst in 1 and a lipoma in 2 children and was inconclusive in 2 children (p<0.001). All who required surgery except one child, were reported on spinal US to have a low lying cord, borderline low cord or tethered cord (p<.05). No child who was reported to have a normal spinal US required de-tethering at a later stage. Spinal US had an overall sensitivity of 91% and specificity of 75% compared to MRI for detecting spinal cord anomalies in children with ARM CONCLUSIONS: Spinal US performed in a tertiary pediatric imaging department was a good screening test for spinal cord anomalies in children with ARM. The finding of a low, borderline low or tethered cord on US mandates an MRI to confirm the findings and correlates with the need for operative correction of spinal cord tethering. STUDY TYPE Clinical research paper. LEVEL OF EVIDENCE 2.
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Affiliation(s)
- Susan Jehangir
- Department of Paediatric Surgery, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Susan Adams
- Department of Paediatric Surgery, Sydney Children's Hospital, Randwick, Sydney, NSW, Australia
| | - Tracey Ong
- Department of Paediatric Surgery, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Camille Wu
- Department of Paediatric Surgery, Sydney Children's Hospital, Randwick, Sydney, NSW, Australia
| | - Robert Goetti
- Department of Medical Imaging, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Adam Fowler
- Department of Neurosurgery, The Children's Hospital at Westmead, Sydney, NSW, Australia
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12
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Tethered cord in children with anorectal malformations with emphasis on rectobladder neck fistula. Pediatr Surg Int 2019; 35:221-226. [PMID: 30413919 DOI: 10.1007/s00383-018-4399-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/18/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE To find the incidence of tethered cord (TC) in patients with anorectal malformations (ARM) and to determine the relationship between bowel/urinary control and TC in a subset of patients with rectobladder neck fistula (RBNF). METHODS The database of a tertiary medical center was retrospectively collected for all patients treated for ARM from 1980 to 2012. All patients with TC and RBNF were identified. RESULTS Among 790 patients, who underwent screening for TC, 285(36%) were diagnosed with TC. Eleven of 37 screened patients with RBNF were diagnosed with TC. The median follow-up period was 49 months (range 2-222 months). TC was diagnosed in 3/18(16.6%) patients with sacral ratio (SR) ≥ 0.7; 4/12(33.3%) with SR 0.41-0.69; and 4/7(57.1%) patients with SR 0-0.4. The association of TC in RBNF patients had a negative influence in the prognosis for bowel and urinary control. CONCLUSION The incidence of TC among patients with ARM is 36%. Incidence of TC among patients with RBNF correlates with SR value and is higher with lower SR. Patients with RBNF and TC have dismal prognosis for bowel control, unrelated to their SR status. Many unresolved questions related to the management of ARM patients with asymptomatic TC still remain.
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Stoll C, Dott B, Alembik Y, Roth MP. Associated anomalies in cases with anorectal anomalies. Am J Med Genet A 2018; 176:2646-2660. [PMID: 30548801 DOI: 10.1002/ajmg.a.40530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 08/07/2018] [Accepted: 08/10/2018] [Indexed: 11/06/2022]
Abstract
Anorectal anomalies (ARA) are common congenital anomalies. The etiology of ARA is unclear and its pathogenesis is controversial. Cases with ARA often have other non-ARA-associated congenital anomalies. The purpose of this study was to assess the prevalence and the types of these associated anomalies in a defined population. The associated anomalies in cases with ARA were collected in all live births, stillbirths, and terminations of pregnancy during 29 years in 387,067 consecutive births in the area covered by our population-based registry of congenital malformations. Of the 202 cases with ARA, representing a prevalence of 5.21 per 10,000, 100 (49.5%) had associated anomalies. There were 7 (3.3%) cases with chromosomal abnormalities, and 31 (15.3%) nonchromosomal recognized dysmorphic conditions, including 17 cases with Vertebral defects, Anal atresia, Cardiac septal defects, esophageal atresia or TracheoEsophageal fistula, Renal anomalies and radial Limb defects association. Sixty two (30.7%) of the cases had nonsyndromic multiple congenital anomalies (MCA). Anomalies in the urogenital, the musculoskeletal, the cardiovascular, the digestive, and the central nervous systems were the most common other anomalies in the cases with MCA. The anomalies associated with ARA could be classified into a recognizable malformation syndrome or pattern in 38 out of the 100 cases (38%) with associated anomalies. This study included special strengths: each affected child was examined by a geneticist, all elective terminations were ascertained, and the surveillance for anomalies was continued until 2 years of age. In conclusion, the overall prevalence of associated anomalies, which was close to one in two cases, emphasizes the need for a routine screening for other anomalies in cases with ARA.
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Affiliation(s)
- Claude Stoll
- Laboratoire de Génétique Médicale, Faculté de Médecine, Université de Strasbourg, Strasbourg cedex, France
| | - Beatrice Dott
- Laboratoire de Génétique Médicale, Faculté de Médecine, Université de Strasbourg, Strasbourg cedex, France
| | - Yves Alembik
- Laboratoire de Génétique Médicale, Faculté de Médecine, Université de Strasbourg, Strasbourg cedex, France
| | - Marie-Paule Roth
- Laboratoire de Génétique Médicale, Faculté de Médecine, Université de Strasbourg, Strasbourg cedex, France
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Farghaly YT, Ettaby AN, Waheeb SM, Moghazy KM, El. Tomey MA. Postoperative MRI for anorectal malformations. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2018. [DOI: 10.1016/j.ejrnm.2018.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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15
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Vilanova-Sanchez A, Reck CA, Sebastião YV, Fuchs M, Halleran DR, Weaver L, Gregory Bates D, Gasior AC, Maloof T, Hoover EJ, Jaggers J, Gagnon R, Ching CC, Dajusta D, Jayanthi VR, Levitt MA, Wood RJ. Can sacral development as a marker for caudal regression help identify associated urologic anomalies in patients with anorectal malformation? J Pediatr Surg 2018; 53:2178-2182. [PMID: 29680275 DOI: 10.1016/j.jpedsurg.2018.03.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 03/06/2018] [Accepted: 03/15/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND AIM The sacral ratio (SR) is a well-established tool to quantify sacral development in patients with anorectal malformations (ARM) and can be used as a predictor of fecal continence. We hypothesized that a lower SR correlated with the presence of urologic and renal malformations. METHODS We retrospectively reviewed the medical records of patients with ARM treated at our center from 2014 to 2016. We measured the lateral SR as a marker for sacral development and assessed the spine for the presence of tethered cord (TC). Urological and renal anomalies, including single kidney, hydronephrosis, hypospadias, vesicoureteral reflux (VUR), ectopic ureter, and penoscrotal transposition were assessed. Analysis of variance (ANOVA), t-tests, and multivariable linear regression were used to test for differences in SR with consideration of associated urologic malformations and tethered cord. RESULTS 283 patients with ARM were included for analysis (156 females). The median age was 39months (10-90). Among these, 178 (55.6%) had 1 or more urologic malformations, and 81 (25.3%) had a TC. Hydronephrosis, high-grade VUR (3-5), solitary kidney, and tethered cord were significantly associated with lower SR (p<0.01). In multivariable regression models, the presence of urologic abnormalities remained significantly associated with lower a SR despite the presence or absence of TC (p<0.001). CONCLUSION SR is a potentially useful indicator of certain urologic anomalies including hydronephrosis, high grade VUR, and solitary kidney in patients with ARM. This association is independent of the presence of TC. A sacral ratio as a part of the VACTERL screening can help the surgeon identify which patients need closer urologic follow up. LEVEL OF EVIDENCE IV.
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Affiliation(s)
| | - Carlos A Reck
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, OH
| | - Yuri V Sebastião
- Center for Surgical Outcomes Research, Center for Innovation in Pediatric Practice, Nationwide Children's Hospital, Columbus, OH
| | - Molly Fuchs
- Pediatric Urology Department, Nationwide Children's Hospital, Columbus, OH
| | - Devin R Halleran
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, OH
| | - Laura Weaver
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, OH
| | - D Gregory Bates
- Children's Radiological Institute, The Ohio State College of Medicine and Public Health, Columbus, OH
| | - Alessandra C Gasior
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, OH
| | - Tassiana Maloof
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, OH
| | - Erin J Hoover
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, OH
| | - Jordan Jaggers
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, OH
| | - Renae Gagnon
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, OH
| | - Christina C Ching
- Pediatric Urology Department, Nationwide Children's Hospital, Columbus, OH
| | - Daniel Dajusta
- Pediatric Urology Department, Nationwide Children's Hospital, Columbus, OH
| | - Venkata R Jayanthi
- Pediatric Urology Department, Nationwide Children's Hospital, Columbus, OH
| | - Marc A Levitt
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, OH
| | - Richard J Wood
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, OH
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Veras LV, Smith JR, Gosain A. Lack of disparities in screening for associated anomalies in children with anorectal malformations. J Surg Res 2018; 231:10-14. [PMID: 30278916 DOI: 10.1016/j.jss.2018.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 04/18/2018] [Accepted: 05/04/2018] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Patients with anorectal malformations (ARM) often have associated congenital anomalies and should undergo several screening exams in the first year of life. We hypothesized that racial and socioeconomic disparities exist in the screening processes for these patients. METHODS After IRB approval, a retrospective review of patients with ARM born between 2005 and 2016 was performed at a quaternary care children's hospital. Demographics including gender, race, insurance, and zip code were collected. Zip code was used as a surrogate for median income. Chart review was performed to identify anomaly type and whether Vertebral defects, Anorectal malformations, Cardiac defects, Tracheo-Esophageal fistula, Renal anomalies, and Limb abnormalities screening was performed within 1 y of age. Descriptive statistics and chi square analyses were performed. RESULTS One hundred patients (59% male, 68% low malformation) were identified. African American and Caucasian subjects represented 41% and 40% of the population, respectively. Overall, 68 of 100 patients had at least one screening test for each of the Vertebral defects, Anorectal malformations, Cardiac defects, Tracheo-Esophageal fistula, Renal anomalies, and Limb abnormalities associations. Although some minor differences were noted (more African Americans received skeletal survey than Caucasians, 80.5% versus 60%, P = 0.00335), no pattern of systematic bias in the receipt or timing of screening was evident based on race, insurance, or income. CONCLUSIONS There do not appear to be racial or socioeconomic disparities in screening for associated anomalies in patients with ARM. However, overall gaps in screening still exist, and work must be carried out to appropriately screen all patients for associated anomalies.
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Affiliation(s)
- Laura V Veras
- Division of Pediatric Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Justin R Smith
- Division of Pediatric Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Ankush Gosain
- Division of Pediatric Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee; Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, Tennessee.
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Yang Z, Gao L, Jia H, Bai Y, Wang W. The Expression of Shh, Ptch1, and Gli1 in the Developing Caudal Spinal Cord of Fetal Rats With Anorectal Malformations. J Surg Res 2018; 233:173-182. [PMID: 30502245 DOI: 10.1016/j.jss.2018.08.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 06/28/2018] [Accepted: 08/01/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Postoperative incontinence and constipation still remain the major complications of anorectal malformations (ARMs), despite improvements in their treatment. One of the most important factors that affect postoperative anorectal function is malformations in the lumbosacral spinal cord. However, far too little attention has been paid to the underlying mechanism that produces these malformations. MATERIALS AND METHODS The levels of sonic hedgehog (Shh), patched homolog 1 (Ptch1), and zinc finger-containing transcription factors 1 (Gli1) expression were investigated in the lumbosacral spinal cord in ethylenethiourea-exposed rat fetus with ARMs, and Shh, Ptch1, and Gli1 expression was confirmed with immunohistochemical staining, quantitative real-time polymerase chain reaction, and western blot analyses during lumbosacral spinal cord development both in the ARMs and normal rat embryos. RESULTS Our results have shown that Shh, Ptch1, and Gli1 expression in the lumbosacral spinal cord of rat embryos with ARMs was decreased at both the messenger RNA and protein levels, when compared with their expression levels in normal tissues (P < 0.05). CONCLUSIONS This study demonstrated that the expression of Shh, Ptch1, and Gli1 in lumbosacral spinal cord was remarkably reduced during late developmental stages in fetal rats with ARMs. These findings offered some important insights into the involvement of the Shh-Ptch1-Gli1 signaling pathway in the pathogenesis of lumbosacral spinal cord maldevelopment in rat fetus with ARMs, which leads to complications after procedures for ARMs.
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Affiliation(s)
- Zhonghua Yang
- Department of Pediatric Surgery, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Linlin Gao
- Key Laboratory of Health Ministry for Congenital Malformation, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Huimin Jia
- Department of Pediatric Surgery, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Yuzuo Bai
- Department of Pediatric Surgery, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Weilin Wang
- Department of Pediatric Surgery, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China.
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Tuite GF, Thompson DNP, Austin PF, Bauer SB. Evaluation and management of tethered cord syndrome in occult spinal dysraphism: Recommendations from the international children's continence society. Neurourol Urodyn 2017; 37:890-903. [PMID: 28792087 DOI: 10.1002/nau.23382] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 06/01/2017] [Indexed: 01/05/2023]
Abstract
AIMS As awareness and frequency of tethered spinal cord (TSC) related to occult spinal dysraphism (OSD) has increased with magnetic resonance imaging (MRI), variability exists in its evaluation and management. Due to no published level I data, we summarize the current International Children's Continence Society (ICCS) recommendations for diagnosis and treatment of OSD. METHODS Guidelines were formulated based on analysis of pertinent literature and consensus among authors. This document was vetted by the multidisciplinary members of the ICCS via its website before submission for peer review publication. RESULTS The more frequent diagnosis of OSD is associated with increased operative intervention. Spinal cord untethering (SCU) has a highly variable risk profile, largely dependent on the specific form of OSD. Progressive neurological deterioration attributed to "tethered cord" may occur, with or without surgery, in selected forms of OSD whereas other cohorts do well. CONCLUSION Infants with classic cutaneous markers of OSD, with progressive neurologic, skeletal, and/or urologic findings, present no diagnostic or therapeutic dilemma: they routinely undergo MRI and SCU. Conversely, in asymptomatic patients or those with fixed, minor abnormalities, the risk profile of these OSD cohorts should be carefully considered before SCU is performed. Irrespective of whether or not SCU is performed, patients at risk for progression should be followed carefully throughout childhood and adolescence by a multidisciplinary team.
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Affiliation(s)
- Gerald F Tuite
- Institute of Brain Protection Science, Division of Pediatric Neurosurgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Dominic N P Thompson
- Department of Paediatric Neurosurgery, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Paul F Austin
- Department Surgery, Division of Urology, Texas Children's Hospital & Scott Department of Urology, Baylor College of Medicine, Houston, Texas
| | - Stuart B Bauer
- Department of Urology, Boston Children's Hospital, Boston, Massachusetts
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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: 1.9] [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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Abstract
PURPOSE The present study aims to identify clinical and pathological factors that can predict the risk of spinal cord anomalies (SCA) in patients with anorectal malformations (ARM), the need for neurosurgery, and to define the impact of SCA on the outcome of patients with ARM. METHODS A 16-year retrospective analysis of all patients treated at a single tertiary children's Hospital with diagnosis of ARM. Data were collected to assess the impact of defined clinical characteristics on prevalence of SCA (detected at MRI). Children surgically treated or not for SCA were compared for age, clinical symptoms and type of anomalies at surgery or at last follow-up, respectively. Moreover, patients with intermediate/high ARMs, with or without SCA were compared for neurogenic bladder (NB), constipation, soiling and need for bowel management (BM). RESULTS Two hundred and seventy-five children were treated for ARM in the study period, 142 had spinal MRI that showed SCA in 85. Patients with SCA had significantly higher prevalence of preterm birth (p < 0.05), cardiac anomalies (p = 0.02), vertebral anomalies (p = 0.0075), abnormal sacrum (p < 0.0001), and VACTERL association (p = 0.0233). Ten patients were surgically treated for SCA. The prevalence of neurological bladder and neuro-motor deficits, of vertebral and genital anomalies, particularly cryptorchidism, was significantly higher in the operated group (p < 0.01, for each analysis). In patients with intermediate/high ARMs, no significant difference was observed between those with or without SCA, in terms of prevalence of NB, intestinal function and need for BM. CONCLUSIONS In patients with ARM, factors that can predict a higher prevalence of SCA and also determine an increased indication to neurosurgery may be identified. SCA by itself does not seem to affect the functional prognosis of children with intermediate/high ARM. These data may help physicians in stratifying the clinical and diagnostic pathway of patients with ARM.
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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: 2.3] [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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Lane VA, Ambeba E, Chisolm DJ, Lodwick D, Levitt MA, Wood RJ, Deans KJ, Minneci PC. Low vertebral ano-rectal cardiac tracheo-esophageal renal limb screening rates in children with anorectal malformations. J Surg Res 2016; 203:398-406. [DOI: 10.1016/j.jss.2016.03.056] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 03/03/2016] [Accepted: 03/24/2016] [Indexed: 10/22/2022]
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Abstract
Cloacal malformations represent one of the most complex conditions among anorectal malformations. Urologic conditions occur with an increased frequency in cloaca patients compared to patients with other types of ARM. The morbidity of the upper and lower urinary tract dysfunction/malformations at times can be severe; manifested by urinary tract infection, lower urinary tract symptoms, urinary incontinence, chronic kidney disease, and even end stage renal disease. Long-term follow-up of patients with cloaca has described significant chronic kidney disease and end-stage renal disease. Whether this rate of chronic kidney disease is a function of intrinsic renal dysplasia or acquired renal injury from neurogenic bladder is currently unknown. However, it is well known that severe lower urinary tract dysfunction, no matter the etiology, poses significant risk to the upper tracts when untreated. Neonatal assessment of the urinary tract accompanied by early identification of abnormal structure and function is therefore fundamental to minimize the impact of any urologic condition on the child's overall health. Adequate management of any associated bladder dysfunction is essential to preserving renal function, minimizing risk of urinary tract infection, and potentially avoiding need for future reconstructive surgery. This article summarizes our institution's approach to the ongoing early urologic management in patients with cloaca.
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Affiliation(s)
- Brian A VanderBrink
- Division of Urology, Cincinnati Children's Hospital Medical Center, MLC 5037, 3333 Burnet Ave, Cincinnati, Ohio.
| | - Pramod P Reddy
- Division of Urology, Cincinnati Children's Hospital Medical Center, MLC 5037, 3333 Burnet Ave, Cincinnati, Ohio
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Bruce E, Spencer AO, Albayram MS. Failed caudal block due to physiologic changes associated with a cerebrospinal fluid leak: a case report. Can J Anaesth 2016; 63:603-7. [PMID: 26759160 DOI: 10.1007/s12630-016-0584-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 12/06/2015] [Accepted: 01/06/2016] [Indexed: 11/26/2022] Open
Abstract
PURPOSE The sum of the volumes of brain tissue, cerebrospinal fluid (CSF), and intracranial blood remain constant. This tenet of the Monroe-Kellie hypothesis is most often considered in the setting of intracranial hypertension, but it can also be applied in the setting of CSF volume depletion. We used this hypothesis to explain a case of failed caudal block in a patient with an iatrogenic CSF leak. CLINICAL FEATURES A one-month-old baby (3 kg) born at 35 weeks' gestation presented for right inguinal hernia repair. His past medical history was significant for arthrogryposis (congenital joint contractures in two or more areas of the body) as well as ongoing apneic episodes that required continuous positive airway pressure therapy and neonatal intensive care. An ultrasound confirmed caudal block was completed and within five minutes of the procedure, the patient's heart rate increased, with an accompanying slight increase in T-wave amplitude. Pinch tests revealed anesthesia to the feet bilaterally but insufficient anesthesia to the abdomen. The surgery was delayed but successfully completed under general anesthesia the following week. Magnetic resonance imaging of the brain and spine following the surgery showed a significant CSF leak with engorgement of the epidural venous plexus along the entire spine. These findings were consistent with a CSF leak likely secondary to a prior lumbar puncture (at age 13 days) that was part of the investigation of his respiratory issues. CONCLUSIONS The possible mechanism of this failed caudal block was high systemic absorption of anesthetic given the epidural venous plexus engorgement thus leaving less anesthetic acting within the CSF and on the exiting spinal nerves. Decreased CSF flow in the thecal sac might also have contributed, as might dilution of the remaining local anesthetic caused by large amounts of leaking CSF within the epidural space.
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Affiliation(s)
- Erin Bruce
- Department of Anesthesia, University of Calgary, Calgary, AB, Canada
| | - Adam O Spencer
- Department of Pediatric Anesthesia, Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada.
| | - Mehmet Sait Albayram
- Department of Radiology, Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada
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Dhingani DD, Boruah DK, Dutta HK, Gogoi RK. Ultrasonography and magnetic resonance imaging evaluation of pediatric spinal anomalies. J Pediatr Neurosci 2016; 11:206-212. [PMID: 27857788 PMCID: PMC5108122 DOI: 10.4103/1817-1745.193374] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
CONTEXT Spinal dysraphisms are congenital abnormalities of the spine due to imperfect fusion of midline mesenchymal, bony and neural structures. Imaging plays a vital role in their evaluation as significant portion of patients may present with concurrent anomalies that need to be corrected simultaneously to avoid repeat surgeries. AIMS The aims of the study were to evaluate Spinal dysraphisms using USG and MRI and to correlate imaging findings with operative findings in patients undergoing surgery. SETTINGS AND DESIGN Hospital based observational study conducted over a period of year. MATERIALS AND METHODS 38 cases of both sexes and below 12 years of age with spinal dysraphism were studied. USG was performed in 29 cases where acoustic window was available for proper evaluation. MRI was performed in all cases. USG findings were compared with MRI findings and operative follow up was taken in 23 cases who underwent operative management. STATISTICAL ANALYSIS USED Results were analysed using percentage and arithmetic mean. RESULTS 39.47 % cases were male and 60.53 % cases were female. Neonatal period was the most common presenting age group. Closed spinal dysraphism (63.16%) was more common than open (36.84%). 79.31% cases showed full agreement between spinal USG and MRI examinations and 6 out of 20.69% showed partial agreement. On operative correlation, USG findings were confirmatory in 91.30% cases and MRI findings were confirmatory in 100% cases. CONCLUSIONS USG can be used as the initial modality for evaluation of spinal dysraphism as well as for screening of suspected cases. MRI is indicated to confirm abnormal USG findings, which shows all concurrent abnormalities and also provides additional anatomical details relevant to surgical planning.
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Affiliation(s)
| | - Deb Kumar Boruah
- Department of Radio Diagnosis, Assam Medical College and Hospital, Dibrugarh, Assam, India
| | - Hemonta Kumar Dutta
- Department of Pediatric Surgery, Assam Medical College and Hospital, Dibrugarh, Assam, India
| | - Rudra Kanta Gogoi
- Department of Radio Diagnosis, Assam Medical College and Hospital, Dibrugarh, Assam, India
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Dias M, Partington M. Congenital Brain and Spinal Cord Malformations and Their Associated Cutaneous Markers. Pediatrics 2015; 136:e1105-19. [PMID: 26416933 DOI: 10.1542/peds.2015-2854] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The brain, spinal cord, and skin are all derived from the embryonic ectoderm; this common derivation leads to a high association between central nervous system dysraphic malformations and abnormalities of the overlying skin. A myelomeningocele is an obvious open malformation, the identification of which is not usually difficult. However, the relationship between congenital spinal cord malformations and other cutaneous malformations, such as dimples, vascular anomalies (including infantile hemangiomata and other vascular malformations), congenital pigmented nevi or other hamartomata, or midline hairy patches may be less obvious but no less important. Pediatricians should be aware of these associations, recognize the cutaneous markers associated with congenital central nervous system malformations, and refer children with such markers to the appropriate specialist in a timely fashion for further evaluation and treatment.
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Caruso AM, Catalano P, Li Voti G, Salerno S, Casuccio A, Di Pace MR, Cimador M. Prognostic evaluation of biofeedback response in patients treated for anorectal malformation. J Pediatr Surg 2015; 50:1648-52. [PMID: 25962840 DOI: 10.1016/j.jpedsurg.2015.03.068] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 02/10/2015] [Accepted: 03/21/2015] [Indexed: 12/18/2022]
Abstract
PURPOSE Functional bowel outcome in patients with anorectal malformation often is poor. For fecal incontinence resulting from sphincter dysfunction, biofeedback (BFB) training appears to be effective. The aim of study was to investigate the bowel function in incontinent children treated for ARM, using a clinical score, a manometric and pelvic magnetic resonance evaluation, in order to establish predictive parameters of response after BFB. METHODS 25 children (median age of 6.5 years) with true fecal incontinence were evaluated by clinical score, anorectal manometry and magnetic resonance imaging (MRI). According to these evaluations patients were divided in 4 groups: group 1 (favorables manometry and MRI); group 2 (favorable manometry and unfavorable MRI); group 3 (unfavorable manometry and favorable MRI); group 4 (unfavorables manometry and MRI). All groups started a cycle of BFB and six months after end of BFB, were reevaluated by clinical score and manometry. RESULTS The overall response to BFB was excellent in 44%, discrete in 40% and poor in 16%; a better response was found in groups 1 and 2 than groups 3 and 4. The differences between groups before BFB proportionally correlated with values after BFB; a correlation with genitourinary and spinal anomalies was found. CONCLUSIONS Our results showed that BFB is an effective for fecal incontinence when the assessment pretreatment (functional and morphologic) is favorable; the manometry can evaluate the potential sphincterial recovery after BFB with a further prognostic benefit if correlated to morphologic evaluation with MRI.
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Affiliation(s)
- A M Caruso
- Pediatric Surgical Unit, Department of Mother and Child Care, University of Palermo, Palermo, Italy.
| | - P Catalano
- Pediatric Surgical Unit, Department of Mother and Child Care, University of Palermo, Palermo, Italy
| | - G Li Voti
- Pediatric Surgical Unit, Department of Mother and Child Care, University of Palermo, Palermo, Italy
| | - S Salerno
- Pediatric Surgical Unit, Department of Mother and Child Care, University of Palermo, Palermo, Italy
| | - A Casuccio
- Pediatric Surgical Unit, Department of Mother and Child Care, University of Palermo, Palermo, Italy
| | - M R Di Pace
- Pediatric Surgical Unit, Department of Mother and Child Care, University of Palermo, Palermo, Italy
| | - M Cimador
- Pediatric Surgical Unit, Department of Mother and Child Care, University of Palermo, Palermo, Italy
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VACTERL associations in children undergoing surgery for esophageal atresia and anorectal malformations: Implications for pediatric surgeons. J Pediatr Surg 2015; 50:1245-50. [PMID: 25913268 DOI: 10.1016/j.jpedsurg.2015.02.049] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 02/08/2015] [Accepted: 02/14/2015] [Indexed: 11/22/2022]
Abstract
PURPOSE The aim of this study was to compare the frequency and nature of VACTERL associations between children who underwent surgery for esophageal atresia/tracheoesophageal fistula (EA/TEF) and anorectal malformation (ARM). METHODS We identified all children who underwent surgery for EA/TEF and/or ARM at hospitals participating in the Pediatric Health Information System (PHIS) database between 2004 and 2012. PHIS is an administrative database of free-standing children's hospitals managed by the Child Health Corporation of America (Overland Park, KS) that contains patient-level care data from 43 hospitals. The complete records of patients in this cohort were cross-referenced for diagnoses of vertebral, cardiac, renal and limb anomalies. RESULTS 2689 children underwent repair of esophageal atresia. Mean gestational age was 36.5±3.2weeks and mean birth weight was 2536.0±758.7g. Associated VACTERL diagnoses included vertebral anomaly in 686 (25.5%), ARM in 312 (11.6%), congenital heart disease in 1588 (59.1%), renal disease in 587 (21.8%) and limb defect in 192 (7.1%). 899 (33.4%) had 3 or more anomalies and met criteria for a VACTERL diagnosis. 4962 children underwent repair of ARM. Mean gestational age was 37.4±2.7weeks and mean birth weight was 2895.2±765.1g. Associated VACTERL diagnoses included vertebral anomaly in 1562 (31.5%), congenital heart disease in 2007 (40.4%), EA/TEF in 348 (7.0%), renal disease in 1723 (34.7%) and limb defect in 359 (7.2%). 1795 (36.2%) had 3 or more anomalies and met criteria for a VACTERL diagnosis. CONCLUSION VACTERL associations are relatively common in children with EA/TEF and ARM and occur in specific clusters, with cardiac disease more common in EA/TEF and spinal and renal/urinary anomalies more common in ARM.
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Pelvic floor in females with anorectal malformations--findings on perineal ultrasonography and aspects of delivery mode. J Pediatr Surg 2015; 50:622-9. [PMID: 25840075 DOI: 10.1016/j.jpedsurg.2014.08.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Revised: 07/15/2014] [Accepted: 08/06/2014] [Indexed: 12/29/2022]
Abstract
BACKGROUND Advice on the mode of delivery to females born with anorectal malformation (ARM) is needed. The primary aim was to evaluate the anatomy of the pelvic floor muscles in females with ARM operated with posterior sagittal anorectal plasty (PSARP). The second aim was to correlate the extent of muscle defects to the bowel symptoms. METHODS This interventional study with perineal 4D/3D ultrasonography describes the smooth muscles in the intestinal wall (neo-IAS), external sphincter, levators and anal canal using a muscle score (0-6 worst). The bowel symptoms were prospectively registered with Krickenbeck criteria score (0-7 worst). RESULTS Forty females with different subtypes of ARM, median age 13 (4-21), were followed up regarding bowel symptoms. Seventeen were examined with ultrasonography. Bowel symptoms were similar for those examined with ultrasonography and those not, median score 5 and 3 (1-7) respectively, (p=0.223, Fisher's exact test). All the females had at least one muscular defect. There was no significant correlation between muscle defects and bowel symptoms (p=0.094, Spearman's correlation). CONCLUSION Females with ARM have considerable defects in the pelvic floor without any significant correlation to bowel symptoms. All women with ARM would benefit from individualized predelivery evaluations and caesarian section should be considered.
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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: 0.9] [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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Spinal ultrasound in patients with anorectal malformations: is this the end of an era? Pediatr Surg Int 2014; 30:829-31. [PMID: 24996639 DOI: 10.1007/s00383-014-3546-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/18/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE Even if lumbar magnetic resonance imaging (MRI) is considered the gold standard in the diagnosis of occult spinal dysraphism (SD) in patients with anorectal malformations (ARMs), spinal ultrasound (US) performed up to 5 months of life have been largely used as a screening test. The aim of the present study was to evaluate the accuracy in terms of sensibility and specificity of neonatal US to detect occult SD in patients with ARMs. METHODS Retrospective analysis of all patients treated for ARMs between 1999 and 2013 at our institution who underwent both spinal US (up to 5 months of life) and MRI. Sensibility and specificity have been calculated for US based on MRI results. RESULTS Of 244 patients treated for ARMs at our institution, 82 (34 females, 48 males) underwent both the imaging studies and have been included in this study. ARMs types were: anal stenosis (7), recto-vestibular fistula (19), recto-perineal fistula (3) and cloaca (5) in female and imperforate anus (7) recto-perineal fistula (14), recto-urethral fistula (22), recto-vesical fistula (5) in males. Forty-seven patients (57, 3 % of total, 18 females, 29 males) had some occult SD (tethered spinal cord, spinal lipoma, syringomyelia) at MRI. Only 7 (14, 8 %) patients of those with spinal anomalies at MRI had pathological US studies. In our population, sensibility and specificity of US for diagnosis of occult SD were, respectively, 14, 8 and 100 %. CONCLUSION Since it is well known that a screening test must have a high sensibility, our data suggest that spinal ultrasound is not suitable as a screening test for occult spinal dysraphism in patients with ARMs. Furthermore, we strongly advise against the use of US as a screening test for spinal dysraphism to prevent a false sense of security in physician and patients' families.
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Alamo L, Meyrat BJ, Meuwly JY, Meuli RA, Gudinchet F. Anorectal Malformations: Finding the Pathway out of the Labyrinth. Radiographics 2013; 33:491-512. [PMID: 23479709 DOI: 10.1148/rg.332125046] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Anorectal malformations (ARMs) are a complex group of congenital anomalies involving the distal anus and rectum, as well as the urinary and genital tracts in a significant number of cases. Most ARMs result from abnormal development of the urorectal septum in early fetal life. In most cases, the anus is not perforated and the distal enteric component ends blindly (atresia) or as a fistula into the urinary tract, genital tract, or perineum. ARMs are also present in a great number of syndromes and associations of congenital anomalies. The classification of ARMs is mainly based on the position of the rectal pouch relative to the puborectal sling, the presence or absence of fistulas, and the types and locations of the fistulas. All of this information is crucial in determining the most appropriate surgical approach for each case. Imaging studies play a key role in evaluation and classification of ARMs. In neonates, clinical and radiologic examinations in the first 3 days of life help determine the type of ARM and the need for early colostomy. In older children, preoperative pelvic magnetic resonance imaging is the most efficient diagnostic method for evaluating the size, morphology, and grade of development of the sphincteric musculature.
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Affiliation(s)
- Leonor Alamo
- Department of Diagnostic, Centre Hospitalier Universitaire Vaudois, Rue du Bugnon 46, 1011 Lausanne, Switzerland.
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Cretolle C, Rousseau V, Lottmann H, Irtan S, Lortat-Jacob S, Alova I, Michel JL, Aigrain Y, Podevin G, Lehur PA, Sarnacki S. [Anorectal malformations]. Arch Pediatr 2013; 20 Suppl 1:S19-27. [PMID: 23992833 DOI: 10.1016/s0929-693x(13)71405-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Anorectal malformations (ARM) are the result of an abnormal development of the terminal part of the digestive tract interesting anus and/or rectum that occur early between the sixth and tenth week of embryonic development. They carry a malformation spectrum of severity depending on the level of disruption of the anorectal canal and of the associated caudal malformations (sacrum and spine). ARM are associated in over half the cases with other malformations that can be integrated in some cases in known syndromes. If surgical treatment to restore anatomy as normal as possible is indispensable, post-operative care is essential for these patients whose defecation mechanisms are altered, to reach if not continence, at least a socially acceptable cleanliness.
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Affiliation(s)
- C Cretolle
- Service de Chirurgie pédiatrique, CRMR Malformations ano-rectales et pelviennes rares (MAREP), Hôpital Necker Enfants Malades, Université Paris Descartes, 149 rue de Sèvres, 75015 Paris, France
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The diagnostic value of MRI fistulogram and MRI distal colostogram in patients with anorectal malformations. J Pediatr Surg 2013; 48:1806-9. [PMID: 23932626 DOI: 10.1016/j.jpedsurg.2013.06.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 05/20/2013] [Accepted: 06/08/2013] [Indexed: 11/21/2022]
Abstract
Contrast fistulogram (FG) and distal pressure colostogram (DPCG) are standard diagnostic methods for the assessment of anorectal malformations. Pelvic magnetic resonance imaging (MRI) earned a place among essential diagnostic methods in preoperative investigations after the Currarino syndrome and a high incidence of associated spinal dysraphism were described. The aim of our study was to evaluate the possibility of substituting FG and DPCG by a modified pelvic MRI, e.g. MRI fistulogram (MRI-FG) and MRI colostogram (MRI-DPCG). The prospective study involved 29 patients with anorectal malformations who underwent a modified pelvic MRI. The length and course of fistulas and rectum, and the presence of sacral anomalies were studied on MRI images and compared with images obtained by radiologic examinations. Modified MRI brought identical results as contrast studies in 25 patients when related to the fistula and rectum length and course. MRI was more accurate for the detection of sacral anomalies. MRI-FG was the only imaging method used in the four most recent patients. The results support the assumption that conventional contrast examinations for the assessment of anorectal malformations can be replaced by MRI, thus reducing the radiation dose.
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Comparison of MR and fluoroscopic mucous fistulography in the pre-operative evaluation of infants with anorectal malformation: a pilot study. Pediatr Radiol 2013; 43:958-63. [PMID: 23460374 DOI: 10.1007/s00247-013-2653-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2012] [Revised: 12/12/2012] [Accepted: 01/22/2013] [Indexed: 10/27/2022]
Abstract
BACKGROUND Anorectal malformations are often associated with rectal pouch fistulas. Surgical correction requires accurate evaluation of the presence and position of such fistulas. Fluoroscopy is currently the chosen modality for the detection of fistulas. The role of MRI is unexplored. OBJECTIVE To compare the diagnostic accuracy of MR versus fluoroscopic fistulography in the pre-operative evaluation of infants with anorectal malformation. MATERIALS AND METHODS We conducted a pilot study of infants requiring defunctioning colostomy for initial management of anorectal malformation. Dynamic sagittal steady-state free-precession MRI of the pelvis was acquired during introduction of saline into the mucous fistulas. Findings were compared among MR fistulography, fluoroscopic fistulography and intraoperative inspection. RESULTS Eight children were included. Median age at fistulography was 15 weeks, inter-quartile range 13-20 weeks; all were boys. There was full agreement among MR fistulography, fluoroscopic fistulography and surgical findings. CONCLUSION The pilot data suggest that MR fistulography is promising in the pre-operative evaluation of children with anorectal malformation.
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[Impact of the national rare disease plan on the management of anorectal malformations]. Arch Pediatr 2013; 20:720-2. [PMID: 23742921 DOI: 10.1016/j.arcped.2013.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Accepted: 04/18/2013] [Indexed: 11/22/2022]
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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: 4.8] [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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Preoperative Assessment of Neurovesical Function in Children with Anorectal Malformation: Association with Vertebral and Spinal Malformations. J Urol 2012; 188:943-7. [DOI: 10.1016/j.juro.2012.04.117] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2011] [Indexed: 11/18/2022]
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Chern JJ, Aksut B, Kirkman JL, Shoja MM, Tubbs RS, Royal SA, Wellons JC, Rozzelle CJ. The accuracy of abnormal lumbar sonography findings in detecting occult spinal dysraphism: a comparison with magnetic resonance imaging. J Neurosurg Pediatr 2012; 10:150-3. [PMID: 22747088 DOI: 10.3171/2012.5.peds11564] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The purpose of this study was to correlate lumbar ultrasound (LUS) and MRI findings in patients suspected of having occult spinal dysraphism (OSD). METHODS Over a 5-year period, 1273 consecutive infants underwent an LUS study at a major pediatric tertiary referral center. Of these, 106 patients had abnormal LUS findings suggestive of an OSD, and 103 underwent subsequent MRI studies. The anatomical descriptions of the 2 studies were compared for agreement. RESULTS The average age of the infants was 34 days at the time of the LUS study; OSD was suspected in these patients because of the presence of cutaneous stigmata and congenital defects. The most common anatomical descriptions from the LUS study included a thickened or fatty filum (32 cases), filum cyst (11 cases), and presence of a terminal ventricle or syrinx (9 cases). Using MRI findings as the standard reference, the sensitivity of LUS in detecting a thickened or fatty filum was 20%. The sensitivity of detecting an abnormal conus level at or below L-3 was 76.9%. CONCLUSIONS In the patient population chosen to undergo LUS studies, abnormal findings had poor sensitivity at detecting anatomical findings consistent with OSD.
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Affiliation(s)
- Joshua J Chern
- Pediatric Neurosurgery, Children's Hospital, Birmingham, AL, USA.
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KOO BN, HONG JY, SONG HT, KIM JM, KIL HK. Ultrasonography reveals a high prevalence of lower spinal dysraphism in children with urogenital anomalies. Acta Anaesthesiol Scand 2012; 56:624-8. [PMID: 22338610 DOI: 10.1111/j.1399-6576.2011.02612.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2011] [Indexed: 01/25/2023]
Abstract
BACKGROUND Lower spinal dysraphism is frequently reported in anorectal anomaly combined with urogenital anomalies. The prevalence of the spinal dysraphism has not been comprehensively studied in children with simple urogenital anomalies. We evaluated the prevalence of the spinal dysraphism using ultrasound data of the lumbosacral area in children with urogenital anomalies. METHODS Lumbosacral ultrasound images of 259 children who underwent urological surgery with simple urogenital anomalies were reviewed by an ultrasound-specialized radiologist. The primary outcome measures were the conus medullaris (CM) level and the thickness of the filum terminale. The spinal ultrasonographic findings that were assessed in children showed abnormal spinal findings compared with the other children having normal findings. Two years later, the follow-up telephone interviews were made with the parents of the children with abnormal findings. RESULTS Eighteen children were differentiated as the abnormal finding group. They were suspected of spinal cord tethering. The level of CM was lower, and the filum terminale was thicker compared to the normal group [L2(lower (L)) vs. L1(L), 2.2 mm vs. 0.8 mm]. Of eighteen children, four were confirmed as tethered spinal cord with lipoma on magnetic resonance imaging by the time of surgery, and two were strongly suspected of occult spinal dysraphism (OSD) based on ultrasound findings and follow-up interviews. CONCLUSIONS The prevalence of OSD in children under 24 months of age with simple urogenital anomaly was higher than what was reported for the general population. Ultrasound examination of spinal structures before caudal block in children with urogenital anomaly should be considered.
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Affiliation(s)
- B.-N. KOO
- Department of Anaesthesiology & Pain Medicine; Anaesthesia and Pain Research Institute; Yonsei University College of Medicine; Seoul; Korea
| | - J.-Y. HONG
- Department of Anaesthesiology and Pain Medicine; University of Ulsan College of Medicine, Asan Medical Center; Seoul; Korea
| | - H.-T. SONG
- Department of Radiology; Yonsei University College of Medicine; Seoul; Korea
| | - J. M. KIM
- Department of Anaesthesiology & Pain Medicine; Anaesthesia and Pain Research Institute; Yonsei University College of Medicine; Seoul; Korea
| | - H. K. KIL
- Department of Anaesthesiology & Pain Medicine; Anaesthesia and Pain Research Institute; Yonsei University College of Medicine; Seoul; Korea
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