Outcome in anorectal malformation type rectovesical fistula: a nationwide cohort study in The Netherlands

Factors contributing to emotional distress when caring for children with imperforate anus: a multisite cross-sectional study in China

Background

Imperforate anus (IA) has a life-long impact on patients and their families. The caregivers of children with IA (CoCIA) might experience distress, which could be detrimental to them physically and mentally. However, there are limitations in the related studies. This study aimed to investigate the prevalence of IA and the associated factors contributing to the distress experienced by CoCIA.

Methods

A cross-sectional study was conducted in three tertiary children's hospitals from November 2018 to February 2019. Distress was assessed using the Chinese version of the Kessler Psychological Distress Scale, and possible determinants were assessed by the Caregiver Reaction Assessment, the Parent Stigma Scale, the Parent Perception of Uncertainty Scale, and the Social Support Scale. Demographic and clinical information was also collected. Multiple regression analysis was performed to explore the association between variables.

Results

Out of 229 CoCIA, 52.9% reported experiencing a high level of distress or above. The data analysis revealed that health problems associated with caregiving, stigma, uncertainty, social support, and children who underwent anal reconstruction surgery 1 year before or earlier could significantly predicate caregivers' distress, and these factors could explain 50.1% of the variance.

Conclusions

The majority of the caregivers of children with IA experience high levels of distress, particularly when their children undergo anal reconstruction surgery 1 year before or earlier. Additionally, health problems related to caregiving, stigma, uncertainty, and low social support could significantly predicate caregivers' distress. It is important for clinical staff to be aware of the prevalent situation of caregivers' distress and to make targeted interventions focused on addressing modifiable factors that should be carried out in family-based care.

Evaluation and management of rectovaginal fistula in anorectal malformation: an observational study

PURPOSE

The rectovaginal fistula (RVF) is a type of female ARM in which the rectum terminates in the vagina. Due to its rarity, there are limited reports on its presentation, management, and follow-up. This paper deals with the clinical presentation, management, and outcome of RVF.

METHODS

It was a retrospective cohort study of 10 years. The patients were evaluated for age, clinical presentation, associated anomalies, any prior surgical interventions performed elsewhere, and complications. After workup, the patients underwent three stages of surgery.

RESULTS

Fifty-six patients of RVF were managed. The median age was 13.48 months. The associated anomalies were present in 37 (66%) patients. Posterosagittal and anterosagittal anorectoplasty (PSARP and ASARP) were performed in 29 and 6 patients, respectively. Abdominoperineal pull-through (APPT) was performed in 16 patients of congenital pouch colon. The complications of the first stage included stomal stenosis (4) and stomal prolapse (3). Constipation was present in 39 patients 2 years after the third surgery.

CONCLUSIONS

RVF is a distinct entity, which needs careful clinical examination. With proper planning for diagnosis and treatment, it can be managed at specialized centers. Care may be needed for the associated anomalies. The follow-up is an integral part of its management.

Conservative treatment of rectovesical fistula after leakage following laparoscopic radical resection of rectal cancer

Rectovesical fistula (RVF) is a multifactorial complication that can be caused by different types of laparoscopic surgery, malignant tumor invasion, and chronic inflammation. However, RVF as a postoperative complication of laparoscopic radical rectal cancer is rare and serious. Here, we describe the case of a patient with RVF secondary to pelvic infection that was induced by anastomotic leakage. The patient was managed with conservative treatment, which included double-cavity cannula irrigation-drainage, indwelling balloon urethral catheter, treating the urinary tract infection, partial parenteral nutrition, and enteral nutrition. The patient was discharged after his symptoms had improved. In this case report, we provide a feasible scheme for patients with RVF that is induced by postoperative anastomotic fistula. Inflammatory, infectious, and thrombotic factors are presumable factors that are involved in RVF pathogenesis. These findings provide new directions for the study of RVF induced by anastomotic leakage after rectal cancer surgery. Conservative treatment may be an option in patients who want to avoid an ostomy.

Different Reaction Patterns of Caregivers of Children With Imperforate Anus: A Latent Profile Analysis

AIM

This study aimed to explore how different dimensions of caregivers' reaction shape their caring experience, and the factors associated with different reaction patterns.

DESIGN

A second analysis of a multisite cross-sectional study were conducted. Caregivers of children with imperforate anus (IA) were enrolled in three tertiary children's hospitals in Eastern China between November 2018 and February 2019.

METHODS

The caregiver's experience, stigma feeling, social support level and perception of uncertainty were assessed by Caregiver Reaction Assessment, Parent Stigma Scale, Social Support Scale and Parent's Perception of Uncertainty Scale accordingly. The demographic information of caregivers as well as the children's clinical data were collected. Latent profile analysis was conducted to determine different patterns of caregiver's reaction, and logistics analysis was used to explore the associated factors of the reaction pattern.

FINDINGS

A total number of 229 caregivers (median age = 30, quartiles: 28, 36) were included. Three distinguishable caregiving reaction types were identified (Class 1: low burden and high benefit, 4.8%; Class 2: moderate burden and benefit, 48.9%; Class 3: high burden and low benefit, 46.3%). In logistics analysis, the Class 1 and Class 2 were combined as one group due to the low population in Class 1. The marital status of caregiver (OR = 0.067, 95% CI: 0.006, 0.700, P = 0.024), IA type (OR = 1.745, 95% CI: 1.198, 2.541, P = 0.004), children aged > 2 years (OR = 3.219, 95% CI: 1.364, 7.597, P = 0.008), social support (OR = 0.907, 95% CI: 0.865, 0.951, P < 0.001) and perception of uncertainty (OR = 1.054, 95% CI: 1.026, 1.083, P < 0.001) were associated with different caregiver reaction patterns.

CONCLUSION

Nearly half of the caregivers of children with IA experience reaction of high burden and low benefit, but considerable proportion of caregivers could benefit from the caregiving rather than burden from. Married caregivers may have more negative reaction, especially when children > 2 years and diagnosed with intermediate or high type of IA. However, increasing caregiver's social support and reducing perception of uncertainty may have the potential to modify their reaction pattern.

Relationships between Stigma, Social Support, and Distress in Caregivers of Chinese Children with Imperforate Anus: A Multicenter Cross-Sectional Study

PURPOSE

This study was conducted to explore the relationships between stigma, social support, and distress in caregivers of children with imperforate anus (IA) and determine whether social support mediates the relationship between stigma and distress.

DESIGN AND METHODS

This cross-sectional study was conducted in three tertiary children's hospitals in Eastern China. Primary caregivers completed the Social Support Scale and the Chinese versions of the Parent Stigma Scale and Kessler Psychological Distress Scale, and provided their demographic information. The children's demographic and clinical data were also collected. The hypothesized relations were explored using structural equation modeling via the bootstrap method.

RESULTS

A total of 229 caregivers were enrolled. Distress was positively associated with stigma (r = 0.396, P < 0.01) and negatively associated with social support (r = -0.413, P < 0.01) in all dimensions (r = 0.314-0.346, P < 0.01). Stigma was also negatively correlated with social support (r = 0.280, P < 0.01). Furthermore, social support could partially mediate the relationship between stigma and distress (b = 0.135; 95% confidence interval: 0.072, 0.233).

CONCLUSIONS

Stigma can increase caregivers' distress, while social support can reduce it. Stigma can also negatively influence caregivers' social support. Therefore, stigma should be mitigated to enhance caregivers' social support and decrease their distress.

PRACTICE IMPLICATIONS

The study findings may aid in the identification of the psychological status of caregivers of children with IA, and also inform targeted intervention programs.

Patterns and treatment outcomes of anorectal malformations in Mbarara Regional Referral Hospital, Uganda

BACKGROUND/PURPOSE

Anorectal malformation (ARM) is a common condition. Owing to scarcity of pediatric surgery services in Uganda, however, relatively little is known about this condition.

METHODS

This was a retrospective review of medical records of all patients admitted to Mbarara Regional Referral Hospital (MRRH) from January 2014 to May 2016. MRRH serves 3-8 million people in southwest Uganda. We also enrolled patients prospectively from June 2016 to December 2016.

RESULTS

78 patients were enrolled in the study. 63.38% had delayed diagnosis (presenting >48 h after birth), and most of these were self-referrals from home. The most common malformation was a vestibular fistula. Associated congenital anomalies were seen in 20% of patients, and this was associated with increased mortality. These anomalies included limb, eye, ear and genitourinary anomalies as well as ventricular septal defects, patent ductus arteriosus, spina bifida and tracheoesophageal fistula. Posterior sagittal anorectoplasty (PSARP) was the definitive surgery used. It was performed in 58.97% of the patients. Median age of patients who underwent PSARP was 11 months. 73.91% of PSARP patients had their colostomies closed and 62.5% of these who were ≥3 years old had good continence outcomes. Overall mortality rate was 8.97%.

CONCLUSION

The majority of patients are diagnosed late. Vestibular fistula is the overall most common type of ARM. In males, however, rectourethral fistula is the most common type. Definitive surgery at MRRH is performed late. Continence outcomes are good and comparable to other countries with more resources.

LEVEL OF EVIDENCE

III.

Lack of disparities in screening for associated anomalies in children with anorectal malformations

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.

How to Explore Fetal Sacral Agenesis Without Open Dysraphism: Key Prenatal Imaging and Clinical Implications

The estimated prevalence of fetal caudal dysgenesis is 1 per 100,000 births. The functional prognosis of sacral agenesis is dominated by the large spectrum of associated caudal malformations. Except for cases associated with hydrocephalus secondary to open spinal dysraphism or chromosomal anomalies, association with mental deficiency is rare. We propose a systematic prenatal approach to cases of fetal sacral agenesis based on 9 etiologic items: clinical context, type of sacral dysgenesis, associated spinal cord malformations, mobility of lower limbs, investigation of the presacral region, analysis of the gastrointestinal tract, analysis of the genitourinary tract, associated vertebral defects, and cytogenetic analysis.

Clinical and urodynamic outcomes in children with anorectal malformation subtype of recto-bladder neck fistula

INTRODUCTION

Patients with anorectal malformations (ARMs) have a high incidence of genitourinary anomalies. Those with a recto-bladder neck fistula may represent a high-risk group, but their long-term urologic outcomes are poorly described.

OBJECTIVE

To evaluate the clinical and urodynamic outcomes in a large cohort of patients with an ARM subtype of recto-bladder neck fistula.

MATERIALS AND METHODS

A retrospective cohort study was performed of patients who had been treated for a recto-bladder neck fistula at the present institution since 2007. The primary outcomes were the ability to achieve urinary continence after 4 years of age, and development of a mildly decreased glomerular filtration rate (GFR) or worse (<89 ml/min/1.73 m²). Continence was defined as the ability to store urine for 3-4 h during the day and 8 h overnight without leakage.

RESULTS

Demographic and clinical data are provided in the Summary Table. The most recent urodynamic findings included the presence of detrusor overactivity in 30 (75%) patients, median leak point pressure of 56.0 cmH₂O (range, 14-140), median functional cystometric capacity at 40 cmH₂O of 125.5% age-expected capacity (range, 36-473%), and median maximum cystometric capacity of 131.0% age-expected capacity (range, 44-473%). A mildly decreased GFR or worse developed in 13 (24%) patients. Of the 52 (78%) patients who were followed by pediatric urology at the present institution with a median follow-up of 30.9 months (range, 0.0-86.8), 35 (67%) were at least 4 years of age and could be assessed for continence. Continence was achieved in five (14%) patients voiding spontaneously and 15 (43%) performing CIC. Recurrent urinary tract infections (UTI) (OR 0.70, P = 0.006) were an independent predictor of incontinence, while urethral anomalies (OR 1.40, P = 0.03) were an independent predictor of chronic kidney disease (CKD) on multiple logistic regression analysis.

DISCUSSION

The findings favorably compared with other studies, but were more robust due to the size of the cohort and breadth of urologic evaluation. Limitations included the retrospective design at a single institution. Incomplete clinical data and misclassification of continence may have lead to bias.

CONCLUSIONS

This large cohort of patients with an ARM subtype of recto-bladder neck fistula had a high incidence of genitourinary anomalies. They were rarely able to achieve continence with spontaneous voiding alone and were at risk of developing CKD, both of which were likely multifocal in origin. Long-term urologic follow-up is warranted for patients with a recto-bladder neck fistula.

Advances in minimally invasive neonatal colorectal surgery

Over the last two decades, advances in laparoscopic surgery and minimally invasive techniques have transformed the operative management of neonatal colorectal surgery for conditions such as anorectal malformations (ARMs) and Hirschsprung’s disease. Evolution of surgical care has mainly occurred due to the use of laparoscopy, as opposed to a laparotomy, for intra-abdominal procedures and the development of trans-anal techniques. This review describes these advances and outlines the main minimally invasive techniques currently used for management of ARMs and Hirschsprung’s disease. There does still remain significant variation in the procedures used and this review aims to report the current literature comparing techniques with an emphasis on the short- and long-term clinical outcomes.