1
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den Hollander VEC, Trzpis M, Broens PMA. Relation between the internal anal sphincter and defecation disorders in patients with anorectal malformations. J Pediatr Gastroenterol Nutr 2024. [PMID: 38946687 DOI: 10.1002/jpn3.12302] [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: 07/08/2023] [Revised: 06/05/2024] [Accepted: 06/11/2024] [Indexed: 07/02/2024]
Abstract
OBJECTIVES To investigate associations between the rectoanal inhibitory reflex (RAIR), type of congenital anorectal malformations (ARMs), type of operation that patients with ARM had undergone, and objectively measured fecal incontinence and defecation problems. METHODS We retrospectively included 69 pediatric patients with ARM. All underwent anorectal function tests at the University Medical Center of Groningen during the last 10 years. We assessed anorectal physiology using the Rome IV criteria and anorectal function tests. RESULTS We found the reflex in 67% of patients and all types of ARMs. All patients who had not been operated on, and those who had undergone less extensive surgery possessed the reflex. In contrast, patients who underwent posterior sagittal anorectoplasty, 44% possessed it. We found no difference between mean rectal volumes in patients with and without the reflex (251 mL vs. 325 mL, respectively, p = 0.266). We found that over time, patients without the reflex seemed to develop significantly higher rectal volumes than patients who had it. We did not find a significant difference between the reflex and fecal incontinence; however, it seems that the absence of the reflex, resting anal sphincter pressure, and fecal incontinence are related. CONCLUSION The RAIR seems present in patients with ARM irrespective of their malformation type. Corrective surgery, however, may impair this reflex. Seemingly, its absence results in constipation with enlarged rectal volumes and fecal incontinence. Every effort should be made to preserve this reflex during surgery and to use extensive surgical procedures as sparingly as possible.
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Affiliation(s)
- Venla E C den Hollander
- Department of Surgery, Anorectal Physiology Laboratory, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Monika Trzpis
- Department of Surgery, Anorectal Physiology Laboratory, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Paul M A Broens
- Department of Surgery, Anorectal Physiology Laboratory, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
- Division of Pediatric Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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2
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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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3
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Management of Anorectal Malformations and Hirschsprung Disease. Surg Clin North Am 2022; 102:695-714. [DOI: 10.1016/j.suc.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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4
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Rajasegaran S, Tan WS, Ezrien DE, Sanmugam A, Singaravel S, Nah SA. Utility of postoperative anorectal manometry in children with anorectal malformation: a systematic review. Pediatr Surg Int 2022; 38:1089-1097. [PMID: 35727358 DOI: 10.1007/s00383-022-05152-9] [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] [Accepted: 06/04/2022] [Indexed: 10/18/2022]
Abstract
Children with anorectal malformation (ARM) often continue to have disturbances in bowel function long after reconstructive surgery. Anorectal manometry may be utilized to evaluate bowel function in these children. We aimed to describe the reported protocols and manometric findings in children with ARM post-reconstructive surgery and to investigate the correlation between manometric evaluation and bowel functional outcome. PubMed, EMBASE, and Google Scholar databases were searched from 1980 to 2021. Data were reviewed and extracted independently by two authors, in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Included studies were English articles reporting postoperative assessment of children (≤ 18 years) with ARM using anorectal manometry. From 128 articles obtained in the initial search, five retrospective cohort studies and one prospective study fulfilled inclusion criteria. The rectoanal inhibitory reflex and mean anal resting pressure were parameters most often reported to correlate with postoperative bowel function. The least reported parameters among the studies were high-pressure zone, rectal volume, and rectal sensation. Anorectal manometry could be an objective method providing important information for personalized management of postoperative ARM patients with bowel function issues, but lack of standardized protocols limits a comprehensive analysis of their utility.
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Affiliation(s)
- Suganthi Rajasegaran
- Division of Paediatric and Neonatal Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Wei Sheng Tan
- Division of Paediatric and Neonatal Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia.,Paediatric Surgery Unit, Department of Surgery, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Don Evana Ezrien
- Paediatric Surgery Unit, Department of Surgery, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Anand Sanmugam
- Division of Paediatric and Neonatal Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia.,Paediatric Surgery Unit, Department of Surgery, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Srihari Singaravel
- Division of Paediatric and Neonatal Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia.,Paediatric Surgery Unit, Department of Surgery, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Shireen Anne Nah
- Division of Paediatric and Neonatal Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia. .,Paediatric Surgery Unit, Department of Surgery, University of Malaya Medical Centre, Kuala Lumpur, Malaysia.
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5
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Amerstorfer EE, Schmiedeke E, Samuk I, Sloots CEJ, van Rooij IALM, Jenetzky E, Midrio P. Clinical Differentiation between a Normal Anus, Anterior Anus, Congenital Anal Stenosis, and Perineal Fistula: Definitions and Consequences—The ARM-Net Consortium Consensus. CHILDREN 2022; 9:children9060831. [PMID: 35740768 PMCID: PMC9221870 DOI: 10.3390/children9060831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 05/25/2022] [Accepted: 05/28/2022] [Indexed: 11/16/2022]
Abstract
In the past, an anteriorly located anus was often misdiagnosed and treated as an anorectal malformation (ARM) with a perineal fistula (PF). The paper aims to define the criteria for a normal anus, an anterior anus (AA) as an anatomic variant, and milder types of ARM such as congenital anal stenosis (CAS) and PF. An extensive literature search was performed by a working group of the ARM-Net Consortium concerning the subject “Normal Anus, AA, and mild ARM”. A consensus on definitions, clinical characteristics, diagnostic management, and treatment modalities was established, and a diagnostic algorithm was proposed. The algorithm enables pediatricians, midwives, gynecologists, and surgeons to make a timely correct diagnosis of any abnormally looking anus and initiate further management if needed. Thus, the routine physical inspection of a newborn should include the inspection of the anus and define its position, relation to the external sphincter, and caliber. A correct diagnosis and use of the presented terminology will avoid misclassifications and allow the initiation of correct management. This will provide a reliable comparison of different therapeutic management and outcomes of these patient cohorts in the future.
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Affiliation(s)
- Eva E. Amerstorfer
- Department for Pediatric and Adolescent Surgery, Medical University of Graz, 8036 Graz, Austria;
| | - Eberhard Schmiedeke
- Clinic for Paediatric Surgery and Paediatric Urology, Klinikum Bremen Mitte, 28205 Bremen, Germany;
| | - Inbal Samuk
- Department of Pediatric and Adolescent Surgery, Schneider Children’s Medical Center of Israel, 4920235 Petach Tikva, Israel;
- Sackler Faculty of Medicine, Tel Aviv University, 6997801 Tel Aviv, Israel
| | - Cornelius E. J. Sloots
- Pediatric Surgery Department, Erasmus MC-Sophia Children’s Hospital, 3015 CN Rotterdam, The Netherlands;
| | - Iris A. L. M. van Rooij
- Department for Health Evidence, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands;
| | - Ekkehart Jenetzky
- Faculty of Health, School of Medicine, Witten/Herdecke University, 58448 Witten, Germany;
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Medical Center of the Johannes-Gutenberg-University, 55131 Mainz, Germany
| | - Paola Midrio
- Pediatric Surgery Unit, Cà Foncello Hospital, 31100 Treviso, Italy
- Correspondence: ; Tel.: +39-0422-322298
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Arbizu R, Freiberg B, Rodriguez L. Lower Gastrointestinal Functional and Motility Disorders in Children. Pediatr Clin North Am 2021; 68:1255-1271. [PMID: 34736588 DOI: 10.1016/j.pcl.2021.07.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Functional and motility gastrointestinal disorders are the most common complaints to the pediatric gastroenterologist. Disorders affecting the small intestine carry a significant morbidity and mortality due to the severe limitation of therapeutic interventions available and the complications associated with such interventions. Congenital colorectal disorders are rare but also carry significant morbidity and poor quality of life plus the social stigma associated with its complications. In this review, we summarize the clinical presentation, diagnostic evaluations, and the therapeutic interventions available for the most common and severe gastrointestinal functional and motility disorders of the small bowel, colon, and anorectum.
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Affiliation(s)
- Ricardo Arbizu
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Pediatric Gastroenterology and Hepatology, Neurogastroenterology and Motility Center, Yale School of Medicine, Yale University School of Medicine, Yale New Haven Children's Hospital, 333 Cedar Street, LMP 4093, PO Box 208064, New Haven, CT 06520, USA
| | - Ben Freiberg
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Pediatric Gastroenterology and Hepatology, Neurogastroenterology and Motility Center, Yale School of Medicine, Yale University School of Medicine, Yale New Haven Children's Hospital, 333 Cedar Street, LMP 4093, PO Box 208064, New Haven, CT 06520, USA
| | - Leonel Rodriguez
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Pediatric Gastroenterology and Hepatology, Neurogastroenterology and Motility Center, Yale School of Medicine, Yale University School of Medicine, Yale New Haven Children's Hospital, 333 Cedar Street, LMP 4093, PO Box 208064, New Haven, CT 06520, USA.
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7
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Mert M, Sayan A, Köylüoğlu G. Comparing the fecal continence scores of patients with anorectal malformation with anorectal manometric findings. Pediatr Surg Int 2021; 37:1013-1019. [PMID: 33825956 DOI: 10.1007/s00383-021-04884-4] [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] [Accepted: 03/13/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Patients undergoing surgery for anorectal malformation (ARM) may have defecation-related problems throughout their lives, even if they are perfect treated surgically. Assessment methods are needed to standardize the clinical outcomes of patients with ARM. The aim of this study was to compare the scoring systems (SS) with the anorectal manometry (AM) findings. METHODS The data of patients operated on for ARM were examined. Holschneider's, Rintala's, Krickenbeck's and Peña's questionnaires were executed to the patients and AM was performed. RESULTS Our study was completed with 23 patients. There was a statistically significant relationship between the anal resting pressure and Holschneider's questionnaire (HQ). There was a statistically significant relationship between the area under the curve in the maximum voluntary squeeze pressure-time graph (AUC) and the HQ and Rintala's questionnaire (RQ). A statistically significant difference was found between HQ and RQ scores and high type and low type of ARMs. CONCLUSION In our study, based on AM data, it was found that the use of HQ and RQ from the four SS we compared could be more effective in patients' follow-up. It was concluded that Peña's questionnaire and Krickenbeck's questionnaire should be used to determine the bowel management program of the patients rather than patients' follow-up. LEVELS OF EVIDENCE Level II.
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Affiliation(s)
- Mehmet Mert
- Department of Pediatric Surgery, Health Sciences University Van Education and Research Hospital, Van, Turkey. .,, Halilaga District, Golbasi. Street, Apartment Number:20 İpekyolu, Van, Turkey. .,, Suphan District, Airport Junction 1st Kilometer, Edremit, Van, Turkey.
| | - Ali Sayan
- Department of Pediatric Surgery, Health Sciences University Tepecik Education and Research Hospital, Guney District, 1140/1 Street, Apartment Number:1 Konak, Izmir, Turkey
| | - Gökhan Köylüoğlu
- Department of Pediatric Surgery, Katip Celebi University Medical Faculty Hospital, Airport Station Street, Number:33 Cigli, Izmir, Turkey
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8
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Ambartsumyan L, Shaffer M, Carlin K, Nurko S. Comparison of longitudinal and radial characteristics of intra-anal pressures using 3D high-definition anorectal manometry between children with anoretal malformations and functional constipation. Neurogastroenterol Motil 2021; 33:e13971. [PMID: 32902923 DOI: 10.1111/nmo.13971] [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: 05/13/2020] [Revised: 07/07/2020] [Accepted: 07/24/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Pathophysiology of fecal incontinence (FI) in children with anorectal malformations (AM) is not well understood. Standard or high-resolution anorectal manometry (ARM) does not identify radial asymmetry or localize abnormal sphincter function. 3D high-definition anorectal manometry (HDARM) provides detailed topographic and 3D pressure gradient representation of anal canal. AIMS To compare intra-anal pressure profiles between children with AM and controls using HDARM and to determine the association between manometric properties and reported predictors of fecal continence (AM type, spinal anomaly, and sacral integrity). METHODS HDARM tracings of 30 children with AM and FI referred for ARM were compared with 30 age and sex-matched children with constipation. 2D pressure profiles were used to measure length of high-pressure zone (HPZ). Longitudinal and radial measurements of sphincter pressure at rest and squeeze were taken along each segment in 3D topographic views and compared between groups. KEY RESULTS 3D measurements demonstrated longitudinal and radial differences between groups along all quadrants of HPZ. At rest, intra-anal pressures were lower along the four segments longitudinally across the anal canal and radially along the quadrants in AM group (P < .01). At squeeze, all quadrant pressures were lower in segments 1-4 in AM group (P < .01). Sensation was abnormal in AM group (P < .01). Intra-anal pressures longitudinally and radially were not associated with predictors of fecal continence. CONCLUSIONS AND INFERENCES Children with AM had abnormal sensation and lower pressures longitudinally and radially along all quadrants of anal canal. Manometric properties at rest were not associated with reported predictors of fecal continence.
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Affiliation(s)
- Lusine Ambartsumyan
- Division of Gastroenterology & Hepatology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Michele Shaffer
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Kristen Carlin
- Seattle Children's Research Institute, Seattle, Washington, USA
| | - Samuel Nurko
- Center for Motility and Functional Gastrointestinal Disorders, Boston Children's Hospital, Boston, Massachusetts, USA
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9
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Uemura K, Fukuzawa H, Morita K, Okata Y, Yoshida M, Maeda K. Epithelial and ganglionic distribution at the distal rectal end in anorectal malformations: could it play a role in anastomotic adaptation? Pediatr Surg Int 2021; 37:281-286. [PMID: 33427922 DOI: 10.1007/s00383-020-04786-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/06/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE In anorectal malformations (ARMs), the epithelium of the distal rectal end is not well described. We histomorphologically evaluated epithelial and ganglionic distribution in the distal rectal end of ARMs resected during anorectoplasty to assess similarities and differences with normal anal canal structure. METHODS In this single-center retrospective study, specimens from 60 ARM patients (27 males, 33 females) treated between 2008 and 2019 were evaluated. RESULTS Epithelium type and alignment sequence as well as ganglionic distribution were similar in the distal rectal end and in a normal anal canal. Stratified columnar epithelium (anal transitional zone, ATZ) was seen in 49/60 (81.7%) cases and in all ARM types, including the no-fistula type. Anal crypts were identified in the stratified columnar epithelium (ATZ) of 46/49 (93.9%) patients. Regarding distal rectal end-resecting anorectoplasty, in 90% of patients, resection was performed distal to the Herrmann line. Ganglion cell distribution was exclusively proximal to the Herrmann line. CONCLUSION Epithelial and ganglionic distribution was similar in the distal rectal end of ARMs and in a normal anal canal. The ATZ is the epithelial boundary between the rectum and skin in a normal anal canal. ATZ preservation could reproduce anal canal structure in ARM reconstruction.
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Affiliation(s)
- Kotaro Uemura
- Department of Pediatric Surgery, Kobe Children's Hospital, Chuou-ku Minatojimaminami 1-6-7, Kobe, 650-0047, Japan.,Division of Pediatric Surgery, Department of Surgery, Kobe University School of Medicine, Kobe, Japan
| | - Hiroaki Fukuzawa
- Department of Pediatric Surgery, Kobe Children's Hospital, Chuou-ku Minatojimaminami 1-6-7, Kobe, 650-0047, Japan. .,Division of Pediatric Surgery, Department of Surgery, Kobe University School of Medicine, Kobe, Japan.
| | - Keiichi Morita
- Department of Pediatric Surgery, Kobe Children's Hospital, Chuou-ku Minatojimaminami 1-6-7, Kobe, 650-0047, Japan.,Division of Pediatric Surgery, Department of Surgery, Kobe University School of Medicine, Kobe, Japan
| | - Yuichi Okata
- Division of Pediatric Surgery, Department of Surgery, Kobe University School of Medicine, Kobe, Japan
| | - Makiko Yoshida
- Department of Pathology, Kobe Children's Hospital, Kobe, Japan
| | - Kosaku Maeda
- Department of Pediatric Surgery, Kobe Children's Hospital, Chuou-ku Minatojimaminami 1-6-7, Kobe, 650-0047, Japan.,Division of Pediatric Surgery, Department of Surgery, Kobe University School of Medicine, Kobe, Japan
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10
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Bjørsum-Meyer T, Christensen P, Jakobsen MS, Baatrup G, Qvist N. Correlation of anorectal manometry measures to severity of fecal incontinence in patients with anorectal malformations - a cross-sectional study. Sci Rep 2020; 10:6016. [PMID: 32265467 PMCID: PMC7138810 DOI: 10.1038/s41598-020-62908-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 03/16/2020] [Indexed: 12/15/2022] Open
Abstract
Anorectal malformations (ARM) are a spectrum of anomalies of the rectum and anal canal affecting 1 in 2500 to 5000 live births. Functional problems are common and related to the type of ARM and associated malformations. We aimed to evaluate the results of Three-dimensional High Resolution Anorectal Manometry (3D-HRAM) in long-term follow-up after surgical correction of ARM with special reference to fecal incontinence. Twenty-one patients with anorectal malformations and primary repair at our center consented to participate in the study. Pressures of the anal sphincter muscles and defects were addressed by 3D-HRAM. Fecal incontinence and disease-specific quality of life were evaluated by the Fecal Incontinence Quality of Life score and Wexner incontinence score respectively. The study was approved by the Committee in Health Research Ethics and the Danish Data Protection Agency. Median age was 22(12–31) years and 13(67%) participants were females. Sphincter defect was present in 48% (N = 10) of participants. Participants with sphincter defects had significant higher Wexner score and size of sphincter defects and mean anal squeeze pressure were correlated to Wexner score. Participants with or without sphincter defects did not differ on manometry parameters including resting anal and squeeze pressure or disease-specific quality of life. In a study of the long-term outcome after repair of anorectal malformations we found a higher Wexner incontinence score in the presence of an anal sphincter defect and the size of the defect and mean anal squeeze pressure were correlated to the Wexner incontinence score.
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Affiliation(s)
- T Bjørsum-Meyer
- Department of Surgery, Odense University Hospital, Odense C, 5000, Denmark. .,University of Southern Denmark, Faculty of Health Science, Department of Clinical research, Odense C, 5000, Denmark.
| | - P Christensen
- Department of Surgery, Aarhus University Hospital, Odense, 9000, Denmark
| | - M S Jakobsen
- Department of Pediatrics, Odense University Hospital, Odense, 5000, Denmark
| | - G Baatrup
- Department of Surgery, Odense University Hospital, Odense C, 5000, Denmark.,University of Southern Denmark, Faculty of Health Science, Department of Clinical research, Odense C, 5000, Denmark
| | - N Qvist
- Department of Surgery, Odense University Hospital, Odense C, 5000, Denmark.,University of Southern Denmark, Faculty of Health Science, Department of Clinical research, Odense C, 5000, Denmark
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11
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Abstract
The introduction of posterior sagittal anorectoplasty (PSARP) by deVries and Peña in the early 80s has impacted to the treatment of patients with anorectal malformations (ARM). It gained great recognition worldwide in a very short time, and since then, surgeons dealing with the treatment of this complex malformation could achieve tremendous progress in contemporary management of this anomaly. Despite the growing experience and body of information globally, the treatment of ARMs continues to be a challenge to the pediatric surgeons due to the nature and the variability of the anomaly, and short- and long-term problems continue to exist even after nearly 40 years of the PSARP era. Today, knowing more about it, pediatric surgeons are committed to do more for their ARM patients to have them as physically and socially healthy individuals.
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12
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Higashidate N, Fukahori S, Hashizume N, Ishii S, Saikusa N, Sakamoto S, Kurahachi T, Tanaka Y, Ohtaki M, Yagi M. Does clinical score accurately support fecoflowmetry as a means to assess anorectal motor activity in pediatric patients after anorectal surgery? Asian J Surg 2020; 43:1154-1159. [PMID: 32169517 DOI: 10.1016/j.asjsur.2020.02.011] [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: 01/20/2020] [Revised: 02/23/2020] [Accepted: 02/25/2020] [Indexed: 10/24/2022] Open
Abstract
PURPOSE We investigated the relationship between Krickenbeck score (KS) and fecoflowmetry (FFM) parameters and assessed the characteristics of this new questionnaire test by comparing Kelly's clinical score (KCS) in pediatric patients with anorectal surgery for anorectal malformation (ARM) and Hirschsprung's disease (HD). METHODS We enrolled pediatric patients who underwent anorectal surgery for ARM or HD. Bowel function was assessed with KS and KCS thereafter, FFM and anorectal manometry (AM) were conducted. Patients were divided into subgroups according to each parameter of the scoring system and each FFM parameter was compared among the KCS or KS subgroups, respectively. Moreover, correlation analyses were conducted between FFM and AM parameters. RESULTS The comparison of FFM parameters among the subgroups of KCS showed that Fmax in the KCS staining 2 group was significantly higher than that in KCS staining 1 group and the Fmax in KCS sphincter squeeze 1 group was significantly higher than that in KCS sphincter squeeze 0 group. Moreover, Fmax in the KCS "good" group was significantly higher than that in the KCS "fair" group. The comparison of FFM parameters among the subgroups of KS parameters showed that TR in the no soiling group was significantly higher than that in the KS grade 2 soiling group. FFM and AM parameters showed a significant positive correlation between Fmax and voluntary squeezing anal pressure. CONCLUSION FFM clarified the different characteristics of two scoring systems, namely, KCS reflects the anal sphincter performance, whereas the KS soiling score might reflect the tolerance and evacuation ability.
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Affiliation(s)
- Naruki Higashidate
- Department of Pediatric Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan.
| | - Suguru Fukahori
- Department of Pediatric Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
| | - Naoki Hashizume
- Department of Pediatric Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
| | - Shinij Ishii
- Department of Pediatric Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
| | - Nobuyuki Saikusa
- Department of Pediatric Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
| | - Saki Sakamoto
- Department of Pediatric Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
| | - Tomohiro Kurahachi
- Department of Pediatric Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
| | - Yoshiaki Tanaka
- Division of Medical Safety Management, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
| | - Masahiro Ohtaki
- Department of Pediatric Surgery, Tsuruoka Municipal Shonai Hospital, 4-20 Izumi-cho, Tsuruoka, Yamagata, 997-8515, Japan
| | - Minoru Yagi
- Department of Pediatric Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
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Scientific solution to a complex problem: physiology and multidisciplinary team improve understanding and outcome in chronic constipation and faecal incontinence. Pediatr Surg Int 2020; 36:295-303. [PMID: 31844977 DOI: 10.1007/s00383-019-04605-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/06/2019] [Indexed: 01/25/2023]
Abstract
PURPOSE There is a lack of diagnostic credibility to direct focused management for children with chronic constipation (CC) and faecal incontinence (FI). The aim is to assess the impact of an innovative Children's Anorectal Physiology Service (CAPS) focusing on improving outcomes in children with CC/FI. METHODS Prospective data: demographics, bowel and quality of life (QoL)/risk of distress questionnaires. Diagnostics: awake high-resolution anorectal manometry (AHRAM), endoanal ultrasound and transit marker studies (TMS). RESULTS Total patients: 112; 66 males (59%); median 9 years (17 months to 16 years). Patient groups included: 89 (79%) had functional CC/FI; 9 (8%), Hirschsprung's disease; 12 (11%), anorectal malformations and 2 (2%), trauma. St Marks Incontinence score (SMIS) abnormal in 91 (81%) and Cleveland Constipation Score (CCS) in 101 (90%) patients. Anorectal manometry: 94 (84%) awake and 18 (17%) under anaesthesia. Play specialist input 37 (33%) patients. AHRAM abnormal 65 (58%): sphincter dysfunction 36 (32%) and altered rectal sensation: hyposensitive 22% (20/91); 21% (19/91) hypersensitive. TMS normal in 64 (57%), 17 (15%) slow transit and 27 (24%) rectal evacuatory disorder. Risk of distress in 38% and poor QoL in 55% patients which correlated with abnormal SMIS (p = 0.02). Patient/parent satisfaction improved significantly (p < 0.05). CONCLUSIONS Scientific investigations combined with multidisciplinary team improve patient satisfaction and reduces patient self-report illness severity. A complex problem requires a scientific solution.
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Challenges in Transition of Care for Patients With Anorectal Malformations: A Systematic Review and Recommendations for Comprehensive Care. Dis Colon Rectum 2018; 61:390-399. [PMID: 29420431 DOI: 10.1097/dcr.0000000000001033] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Anorectal malformations are one of the most common congenital intestinal anomalies affecting newborns. Despite advances in neonatal care and surgical techniques, many patients with a history of anorectal malformations are affected by long-term challenges involving bowel and bladder dysfunction, sexual dysfunction, and psychosocial issues. These outcomes or challenges are additionally exacerbated by the lack of a structured transition of care from the pediatric to the adult setting. OBJECTIVE The purpose of this review is to describe the long-term outcomes affecting patients with a history of anorectal malformations, review the current literature on transition of care, and make recommendations for developing a standardized program for transitioning care for a select group of colorectal surgical patients. DATA SOURCES An extensive PubMed review of articles in English was performed to evaluate current best practices for chronic illnesses of childhood with residual symptoms or need for medical care into adulthood. STUDY SELECTION Meta-Analysis of Observational Studies in Epidemiology group guidelines were followed. MAIN OUTCOME MEASURES The primary outcome for this review was the existence of transitional services for patients with a history of anorectal malformations and evaluations of long-term outcomes affecting patients with a history of anorectal malformations. RESULTS Systematic review revealed improved results in transition programs as determined by patient follow-up, medication adherence, and patient and family satisfaction through the use of multidisciplinary teams. Standardized tools for assessing all aspects of patient outcomes and quality of life are essential for describing the burden of disease affecting a transitioning population. LIMITATIONS This is a retrospective review of the current status of a complex and rapidly evolving field of delivery of care. More work is needed to apply uniform approaches and assess the impact, patient outcomes, and quality of life. CONCLUSIONS Patients who undergo childhood procedures for anorectal malformations often experience chronic symptoms related to the bowel, bladder, and reproductive organs, as well as psychosocial disturbances. This population will benefit from appropriate engagement in transitional care plans. See Video Abstract at http://links.lww.com/DCR/A543.
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Chung PHY, Wong KKY, Tam PKH, Leung MWY, Chao NSY, Liu KKW, Chan EKW, Tam YH, Lee KH. Are all patients with short segment Hirschsprung's disease equal? A retrospective multicenter study. Pediatr Surg Int 2018; 34:47-53. [PMID: 29075908 DOI: 10.1007/s00383-017-4202-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/19/2017] [Indexed: 01/12/2023]
Abstract
BACKGROUND/PURPOSE Short segment Hirschsprung's disease (HSCR) carries a better prognosis than long segment disease, but the definition of short is controversial. The objective of this study is to determine anatomically the extent of disease involvement that would be associated with a better functional outcome. METHODS This is a retrospective multicenter (n = 3) study with patients (≥ 3 years) who had transanal pullthrough operation done for aganglionosis limited to the recto-sigmoid colon were reviewed. The extent of disease involvement and bowel resection was retrieved by reviewing the operative records as well as histopathological reports of the resected specimens. Clinical assessment was performed according to the criteria of a seven-itemed bowel function score (BFS) (maximum score = 20). Manometric assessment was performed with anorectal manometry. RESULTS The study period started from 2003 to 45 patients were studied with median age at assessment = 52.0 months and operation = 3.0 months. The disease involvement was categorized into upper sigmoid-descending colon (DC) (n = 8), sigmoid colon (SC) (n = 12), upper rectum (UR) (n = 14) and lower rectum (LR) (n = 11) according to the level of normal biopsy result. There was no significant difference in the age of assessment between the four groups. The median BFSs in the DC, SC, UR and LR were 13, 15, 17 and 17, respectively (p = 0.01). Nine patients from the DC and SC groups reported soiling for more than twice per week. Sub-group analysis comparing patients with and without the entire sigmoid colon resected revealed worse functional outcomes in terms of the incidence of soiling (40.7 vs 22.2%, p = 0.05) and the BFS (14 vs 18, p = 0.04) in the former group. Anorectal manometry did not reveal any significant difference between the four groups, but a higher proportion of patients in the UR and LR groups appeared to have a normal sphincter resting pressure (DC vs SC vs UR vs LR = 62.5 vs 75.0 vs 85.7 vs 80.0%, p = 0.10). CONCLUSION Patients with short segment HSCR are not equal at all. HSCR patients with aganglionosis limited to the rectum without the need of removing the entire sigmoid colon have a better bowel control and overall functional score. Less bowel loss and colonic dissection maybe the underlying reasons. Although future studies with a larger sample size and a longer follow-up period are required to validate the results of this study, it has provided a new insight to the current understanding of short segment disease in HSCR.
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Affiliation(s)
- Patrick Ho Yu Chung
- Division of Pediatric Surgery, Department of Surgery, Queen Mary Hospital, Li Ka Shing Faculty of Medicine, The University of Hong Kong, 102, Pokfulam Road, Hong Kong, China.
| | - Kenneth Kak Yuen Wong
- Division of Pediatric Surgery, Department of Surgery, Queen Mary Hospital, Li Ka Shing Faculty of Medicine, The University of Hong Kong, 102, Pokfulam Road, Hong Kong, China
| | - Paul Kwong Hang Tam
- Division of Pediatric Surgery, Department of Surgery, Queen Mary Hospital, Li Ka Shing Faculty of Medicine, The University of Hong Kong, 102, Pokfulam Road, Hong Kong, China
| | - Michael Wai Yip Leung
- Division of Pediatric Surgery, Department of Surgery, Queen Elizabeth Hospital, Hong Kong, China
| | - Nicholas Sih Yin Chao
- Division of Pediatric Surgery, Department of Surgery, United Christian Hospital, Hong Kong, China
| | - Kelvin Kam Wing Liu
- Division of Pediatric Surgery, Department of Surgery, United Christian Hospital, Hong Kong, China
| | - Edwin Kin Wai Chan
- Division of Pediatric Surgery and Pediatric Urology, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Yuk Him Tam
- Division of Pediatric Surgery and Pediatric Urology, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Kim Hung Lee
- Division of Pediatric Surgery and Pediatric Urology, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
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Abstract
Imperforate anus, a variant of anorectal malformation (ARM), is a common congenital anomaly requiring surgical attention in the newborn period. It may present with a variety of anatomic configurations, largely dependent on the presence and location of a fistula. The location (or characteristics) of a fistula, which usually lies between the gastrointestinal tract and the genitourinary tract or perineum, is often used in determining the type and timing of operative management. This article discusses the work-up and management, modes of treatment and their postoperative outcomes, and continued controversy regarding the use of minimally invasive surgical approaches to ARM.
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Kyrklund K, Pakarinen MP, Rintala RJ. Long-term bowel function, quality of life and sexual function in patients with anorectal malformations treated during the PSARP era. Semin Pediatr Surg 2017; 26:336-342. [PMID: 29110831 DOI: 10.1053/j.sempedsurg.2017.09.010] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Anorectal malformations are an important group of congenital anomalies that vary widely in their anatomical characteristics and complexity. Understanding the long-term functional outcomes after modern treatments, and how these compare to the general population, are essential for ensuring that patients receive optimal, evidence-based care. With increasing appreciation of the wider impact of the illness on patients and their families, minimizing social disability from fecal incontinence and enabling normal social integration from the outset are key management concerns. This review summarizes the current knowledge on the functional outcomes by type of malformation, reflecting on the literature, and our institutional experience over a follow-up period of nearly 30 years.
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Affiliation(s)
- Kristiina Kyrklund
- Department of Pediatric Surgery, Children's Hospital, Helsinki University Central Hospital, P O Box 281, FIN-00029 HUS, Finland
| | - Mikko P Pakarinen
- Department of Pediatric Surgery, Children's Hospital, Helsinki University Central Hospital, P O Box 281, FIN-00029 HUS, Finland
| | - Risto J Rintala
- Department of Pediatric Surgery, Children's Hospital, Helsinki University Central Hospital, P O Box 281, FIN-00029 HUS, Finland.
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Holbrook C, Misra D, Zaparackaite I, Cleeve S. Post-operative strictures in anorectal malformation: trends over 15 years. Pediatr Surg Int 2017; 33:869-873. [PMID: 28616723 DOI: 10.1007/s00383-017-4111-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/30/2017] [Indexed: 12/15/2022]
Abstract
AIM For decades, paediatric surgeons have employed the standard posterior sagittal anorectoplasty (PSARP) approach to deal with patients with anorectal malformations (ARM). In recent years, we noted an apparent increase in the incidence of anal stricture after surgical repair of ARM following the introduction of laparoscopic pull-through and techniques aiming to preserve the internal sphincter-the internal sphincter sparing approach (ISSA). We decided to analyse our data to find out if these new trends had added to the problem of post-operative strictures. METHODS All patients with ARM at our institution from January 2000 to December 2015 were identified. A retrospective case note review was carried out. Data collected included patient demographics, type of ARM, operative details, and post-operative outcomes. RESULTS 114 patients were identified. Ten patients were excluded. Of the remaining 104 children, 48 (46%) were female. Median age was 8.3 (range 1.2-16.8) years. Types of ARM were as follows: perineal fistula (15 patients), anterior stenotic anus (12), imperforate anus without fistula (10), vestibular fistula (32), rectourethral (bulbar) fistula (11), rectourethral (prostatic) fistula (14), rectovesical fistula (7), and cloaca (3). Twenty-seven patients with a perineal fistula or anterior stenotic anus underwent perineal procedures that were variably described by the different operating surgeons. The majority (15 patients) had an anoplasty, 5 had anal transposition, 5 had limited PSARP, and 2 patients had ISSA. Two patients with a cloacal anomaly underwent open cloacal reconstruction. Of the remaining 75 patients, 45 had a PSARP approach, 6 had a laparoscopic-assisted pull-through, and 18 had ISSA. Four girls with vestibular fistula had anal transposition and two boys with imperforate anus without fistula had anoplasty. 15 (14%) children developed anal stricture. Stricture incidence differed according to operation type. PSARP was the most commonly performed procedure, with only 6% developing a stricture. In contrast, 30% of ISSA patients and 50% of children who had laparoscopic pull-through developed a stricture. Strictures also occurred in 11 and 12% of children having anal transposition and anoplasty, respectively. CONCLUSION The laparoscopic-assisted pull-through involves tunnelling the sphincter muscle complex. We found that often the tunnels were not wide enough, resulting in narrowing not just at the ano-cutaneous junction but also at the deeper level. 50% developed strictures. We have modified our technique by ensuring that the tunnels are generous enough to allow the rectum to be pulled through without any resistance. ISSA unfortunately resulted in 30% of our patients developing strictures. This approach, started in 2004, was, therefore, abandoned in 2013. The standard Pena's PSARP, with or without a laparotomy, has stood the test of time. Any modification of this approach must be carefully thought through and audited meticulously. Strictures can cause significant morbidity, which may need several revisions, and the resulting redo anoplasties run the risk of sphincter damage, ironically which the newer modifications of ISSA were trying to conserve.
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Affiliation(s)
| | - Devesh Misra
- Royal London Hospital, Whitechapel Road, London, E1 1BB, UK.
| | | | - Stewart Cleeve
- Royal London Hospital, Whitechapel Road, London, E1 1BB, UK
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