Long term bowel function after repair of anorectal malformations in Uganda

Long-term (> 10 years) bowel function of anorectal malformations: a retrospective single-center study

PURPOSE

To describe the long-term bowel function of anorectal malformation (ARM) patients and explore the potential influence factors.

METHODS

ARM patients with follow-up data > 10 years were included. Cases of cloaca, Currarino syndrome, and VACTERL syndrome were excluded. Rintala score and PedsQL 4.0 were used to assess bowel function score (BFS) and quality of life (QoL). Based on the results, patients were divided into satisfactory group with BFS ≥ 17 and unsatisfactory group with it < 17. Comparisons between the groups were made.

RESULTS

Among the 81 patients were 44 males and 37 females. Follow-up time was 138 (126,151) months. 16 (19.75%) patients had associated anomalies. 23 (28.40%) patients had reoperations, and fistula recurrence was the most common reason. BFS of the patients was 20 (18,20). QoL score was 100 (100,100), which correlated positively with BFS (r = 0.648, P < 0.001). The satisfactory and the unsatisfactory groups had 69 and 12 cases, and their BFS were 20 (20,20) and 11 (8,15) respectively, which had statistical difference (P < 0.001). Total QoL score and psycho-social health score of the unsatisfactory group were lower (P < 0.001). Only reoperations were statistically different between the groups (P < 0.001).

CONCLUSIONS

Long-term (> 10 years) bowel function of ARM patients is good in this study. Defecation problems have negative impacts on QoL and mainly affects their psycho-social health. Primary anorectoplasty is extremely important. Reoperations, which are most commonly seen in recto-urethral fistula recurrence, adversely affect the outcome.

Assessment of long-term quality of life, bowel and voiding function outcomes in patients with anorectal malformation at a single UK centre

AIMS

Assess long-term quality of life (QoL), bowel and voiding function in anorectal malformation (ARM) paediatric patients.

METHOD

Retrospective review of ARM patients between 2007 and 2020 was performed. QoL (all patients), bowel and voiding function (> 5 yo) were assessed using the paediatric quality of life inventory (PedsQL), paediatric incontinence and constipation score (PICS) and dysfunctional voiding scoring system (DVSS), respectively.

RESULTS

There were 122 patients (49% female, 85 > 5 yo) with ARM. Two had died, four refused, twenty-two were non-contactable, leaving ninety-four patients (65 > 5 yo) included. Mean age was 89 months (19-183), and follow-up was 86 months (13-183). Patients had significantly poorer scores for QoL, bowel and voiding function compared to published healthy controls. 57% had poor bowel function, 32% had poor voiding function and 38% required 'ancillary aids' to facilitate function. Patients using 'ancillary aids' for voiding function had a significantly lower QoL (parent: 62 vs 77; p = 0.01, patient: 66 vs 79; p = 0.05). Bowel continence was worse in those with high vs low ARM (13 vs 20, p = 0.004) and timely vs delayed diagnosis (17 vs 24, p = 0.04).

CONCLUSION

Patients with ARM have significantly worse QoL, bowel and voiding function than normal healthy controls. There is a need for long-term monitoring of function and further support for these children.

LEVEL OF EVIDENCE

III.

Hirschsprung disease: a cost analysis study of the direct, indirect costs and financial coping strategies for the surgical management in Western Uganda

BACKGROUND

Surgical management of Hirschsprung disease (HD) in low- and middle-income countries is typically a staged procedure, necessitating multiple hospitalizations and clinic visits increasing family financial burden. Currently, there is limited information on the costs borne by caretakers of children with Hirschsprung disease seeking surgical intervention. This study seeks to measure the costs and economic burden of surgical treatment for Hirschsprung disease in western Uganda.

METHODS

A cross-sectional study using cost analysis was conducted among caretakers of patients who completed surgical treatment of HD between January 2017 and December 2021 at two hospitals in western Uganda. The average direct and indirect costs incurred by caretakers presenting at a public and private hospital were computed.

RESULTS

A total of 69 patients (M: F = 7:1) were enrolled in the study. The median age at diagnosis was 60.5 (IQR 3-151.25) days for children and two-staged pull-through procedure was the common surgery performed. The mean overall cost for treatment was US $960 (SD = $720), with the majority of costs coming from direct medical costs. Nearly half (48%) of participants resorted to distress financing to finance their child's surgical care. The overwhelming majority of patients (n = 64, 93%) incurred catastrophic expenditure from the total costs of surgery for HD, and 97% of participants fell below the international poverty line at the time treatment was completed.

CONCLUSION

Despite the availability of 'free care' from government hospital and non-profit services, this study found that surgical management of Hirschsprung disease imposed substantial cost burden on families with Hirschsprung disease patients.

Anorectal malformations in low and middle-income countries- spectrum, burden and management

The clinical presentation, diagnosis and management of anorectal malformation has been well described in the literature, however the experience with these conditions in low-and middle-income countries is often shaped in unique ways due to the social, cultural and economic factors at work in these regions. This leads to adaptation of modifications in management options for these babies that usually present as delayed cases with added poor prognostic factors like sepsis leading to need for emergency resuscitation and overall increased morbidity and mortality. This article explores the anomaly from a global surgery lens and outlines the spectrum of the anomaly, burden faced in the resource constrained environment and the management options adopted for successful management under the available circumstances.

Pilot bowel management program at Mbarara Hospital, Uganda

PURPOSE

Children with Hirschsprung's disease (HD) and anorectal malformations (ARM) may benefit from a bowel management program (BMP) to treat constipation and fecal incontinence. This study describes a pilot BMP in Uganda.

METHODS

Patients treated for HD or ARM were recruited for the BMP. Local staff underwent training and progressively took over decision-making. The rates of patient involuntary bowel movements (IBMs) and provider confidence were evaluated pre- and post-BMP with questionnaires. The results were compared with Fischer's exact test.

RESULTS

Ten staff-2 surgeons, 6 nurses and 2 physiotherapists-and 12 patients participated. Patient median age was 4.5 years (IQR 3-6.6) and ten were male. Ten reported at least daily IBMs prior to the BMP. All patients underwent a clean-out. The parents were then taught to perform daily enemas or irrigations. Specific regimens were determined by patient history and imaging and titrated throughout the BMP. There were differences in the rates of both daytime and nighttime IBMs before and after the BMP (p = 0.0001 and 0.002, respectively). All staff reported increased confidence.

CONCLUSIONS

We describe the first BMP in Uganda. BMPs can successfully treat constipation and fecal incontinence in low-income countries, although there are challenges with resources and follow-up.

Bowel function at preschool and early childhood age in children with long-segment Hirschsprung disease

Bowel dysfunction has been proven to be the most typical complication of long-segment Hirschsprung disease (LSHD). Additionally, bowel dysfunction in preschool and early childhood should be properly assessed, because it may result in persistent bowel dysfunction, social issues, and depression in adolescence and adulthood. This study evaluated bowel function during preschool and early childhood in patients with LSHD. A cross-sectional bowel function score (BFS) questionnaire survey was conducted on 270 infants with short-segment Hirschsprung disease (SSHD) and LSHD who underwent pull-through (PT) between January 2014 and December 2019 at the Children's Hospital of Nanjing Medical University. One hundred ninety patients who consented to the survey were asked to complete the questionnaire and were divided into two groups: the LSHD group (n = 42) and the SSHD group (n = 148). Bowel function outcomes were assessed by using a questionnaire. The total BFS score in the LSHD group was significantly lower than that in the SSHD group (15.0 [14.0, 17.0] vs. 18.0 [16.0, 19.0], p < 0.05) and did not improve with age (p > 0.05). Independent BFS items with lower scores were discovered in LSHD than in SSHD, including the capacity to hold back defecation, feeling/reporting the urge to defecate, frequency, soiling, and accidents (all p < 0.05). After subgroup analysis of follow-up age (3-5 years, 5 ~ 7 years, and > 7 years), there was no difference between the score of ability to hold back defecation over 7 years old and feeling/reporting the urge to defecate over 5 years old (all p > 0.05). The frequency and soiling scores were lower in the LSHD group than in the SSHD group over 5 years of age (all p < 0.05). Fortunately, there was no difference in constipation scores and social problems between the LSHD and SSHD groups in every sub-follow-up group (all p > 0.05).  Conclusion: Overall, bowel function at preschool and early childhood age was poorer in LSHD than in SSHD and did not improve with age. However, the ability to hold back defecation and feeling/reporting the urge to defecate with age in LSHD may be similar to those in SSHD. Simultaneously, the frequency, soiling, and number of accidents were consistently worse in the LSHD group.  Trial registration: This study was retrospectively registered in the ClinicalTrials database.gov (NCT05461924) in August 2022. What is Known: • Bowel function in SSHD is satisfactory or near-normal, and the general consensus is that the longer the aganglionic segment, the worse the bowel function after surgery. • Bowel functional outcomes of LSHD were not defined, and the limited reports of bowel functional outcomes compared with SSHD were extensively varied. Bowel dysfunction at preschool and early childhood may lead to persistent bowel dysfunction, social problems, and depression in adolescence or adulthood. What is New: • Bowel function in preschool and early childhood in patients with LSHD has not been defined and should be thoroughly assessed in a larger group of patients with precise definitions of incontinence or soiling. • The present study was primarily designed to evaluate bowel function at preschool and early childhood age in LSHD compared with SSHD in a relatively large number of HD cases using BFS.

Significance of searching for ganglia in the terminal rectum/fistula of complex anorectal malformations: Related to defecation function

Background

The need to search for ganglia in the terminal rectum/fistula of complex anorectal malformations (ARMs) remains controversial. This study aims to evaluate the relationship between ganglia absence in the terminal rectum/fistula and defecation function after anoplasty.

Methods

A retrospective review of patients who received anoplasty for treating male imperforate anus with rectobulbar (RB)/rectoprostatic (RP) fistulas at a tertiary pediatric hospital was conducted with registered demographic data, imaging study results, and information on the terminal rectum/fistula specimen (excision extension and pathological findings). According to the pathological findings, patients were divided into Groups 1 (ganglia absence) and 2 (ganglia presence). Furthermore, the postoperative defecation function was evaluated using various rating scale questionnaires. Statistical analysis was performed using SPSS 22.0.

Results

Of the 62 patients, 18 (29.0%) showed ganglia absence in the terminal rectum/fistula. By analyzing the imaging data, spinal anomalies and spinal cord anomalies were found in 30.6% (19/62) and 56.5% (35/62) of patients, respectively. Baseline information was comparable between Groups 1 and 2 (P > 0.05). For defecation function, there were no significant differences in Kelly scores between the two groups (4.0 ± 0.8 vs. 4.4 ± 1.1, P = 0.177), while Krickenbeck (3.7 ± 1.8 vs. 5.2 ± 1.4) and Rintala (13.7 ± 3.6 vs. 16.0 ± 2.7) scores in Group 1 were significantly lower than those in Group 2 (both P < 0.05). The overall incidence of constipation was 50% (31/62), being higher for Group 1 than Group 2 (77.5% vs. 38.6%, P = 0.002). The area under the curve of ganglia absence for predicting constipation was 0.696, with 77.8% sensitivity and 61.4% specificity.

Conclusion

Ganglia absence in the terminal rectum/fistula of male imperforate anus with RB/RP fistulas is associated with constipation after anoplasty, but it has limited predictive value for postoperative constipation. It is necessary to search for ganglia in the terminal rectum/fistula, both intraoperatively and postoperatively.

Social injustice symposium: Urban, rural, and global disparities in access to care

BACKGROUND

Barriers in access to pediatric surgical care are common in low- and middle-income countries (LMICs), but also exist in high-income countries, particularly in urban and rural areas.

METHODS

This article describes "Disparities in Access to Care"-held within the Social Injustice Symposium at the 2020 American Pediatric Surgical Association (APSA) Annual Meeting.

RESULTS

This symposium outlined disparities in access to care, illustrated by examples from pediatric trauma and neonatal surgery in U.S. urban, U.S. rural, and non-U.S. global locations (LMICs). Geographic and financial challenges were common to families from the rural U.S. and LMICs. In contrast, families in U.S. urban settings generally do not face geographic barriers, but are often economically and racially diverse and many face complex societal factors leading to poor outcomes. Systemic processes must be changed to improve pediatric surgical health outcomes.

CONCLUSION

A comprehensive health system with an equal emphasis on supportive care and surgery is required in all settings. Global collaboration and partnerships can provide an avenue for advocacy and strategic innovation to improve quality of care.

LEVEL OF EVIDENCE

Ⅴ.

The Efficacy of Biofeedback Therapy for the Treatment of Fecal Incontinence After Soave Procedure in Children for Hirschsprung's Disease

Introduction: Hirschsprung's disease is a common digestive tract malformation in children, and the Soave procedure is one of the classic surgical methods for Hirschsprung's disease (HD). Fecal incontinence is one of the most common postoperative complications that can cause significant distress to the patients and their family, the incidence of which is 20% in a recent series. Biofeedback therapy (BFT) can be an effective treatment for managing anorectal disorders, but there has been little report of the efficacy of BFT for the treatment of fecal incontinence after the Soave procedure, and the main objective of this study is to evaluate it. Methods: We retrospectively analyzed postoperative fecal incontinence in 46 children who received the Soave procedure for HD and who received BFT at our institution from March 2016 to February 2020, which included 38 males and 8 females (mean age 8.1 years, from 3.7 to 14 years). Anal sphincter contraction training was performed using BFT for 10 days per session in the hospital, one time each day, and 20 min each time. BFT was performed by employing visual and verbal feedback techniques using the biofeedback instrument. Long-term functional outcomes were objectively assessed using the Rintala Bowel Function Score (RBFS), and the patients were scored according to the sum total as excellent (18-20 points, 0 case), good (11-16 points, 0 case), fair (9-11 points, 9 cases), or poor (6-9 points, 37 cases). Defecation questionnaires and anorectal manometry were completed pretreatment and after three, six, or nine sessions, and primary outcome measures of anorectal manometry were anal maximal contraction pressure (AMCP), anal longest contraction time (ALCT), rectal rest pressure (RRP), and anal rest pressure (ARP). Results: Followed up from 6 months to 4 years, the symptoms of fecal incontinence disappeared completely in 39 (84.78%) patients. Among them, 14 (30.43%) had complete disappearance of symptoms after 3 sessions of treatment, 25 (54.34%) patients had improved symptoms after 6 sessions of treatment, symptoms completely disappeared after 6 sessions of treatment, and 7 (15.22%) cases still suffered fecal incontinence mildly. The AMCP after three and six sessions in the poor group was significantly increased compared with that before treatment [(85.87 ± 31.75) mmHg vs. (135.33 ± 37.69) mmHg vs. (128.41 ± 33.45) mmHg, P < 0.05]. The ALCT and ARP showed the same trend, while the RRP after three and six sessions were not significant (P > 0.05). The mean (±SD) score of the RBFS increased from 9 to 17.40 ± 0.84 in the fair group, while it increased from 7.22 ± 0.76 to 16.58 ± 1.66 in the poor group after six sessions (P < 0.05). Conclusion: Biofeedback therapy is a safe and effective treatment of fecal incontinence after the Soave procedure of children for Hirschsprung's disease. It is beneficial to design the individualized treatment programs for the children with varying degrees of fecal incontinence.

Management of postoperative fecal incontinence by pediatric surgeons in Nigeria: a pilot study

Background

Fecal incontinence is a challenging problem in pediatric surgical practice as it occurs in 25 to 50% of patients who have undergone surgery for anorectal malformation and in 5 to 23% after transanal pull-through for Hirschsprung disease. Fecal incontinence impacts on the quality of life of patients; hence, it is important that optimum management is instituted. The management of fecal incontinence in children in sub-Saharan Africa is largely unreported. The study, therefore, evaluated the management practices regarding fecal incontinence by pediatric surgeons in Nigeria.

Results

A total of 37 pediatric surgeons participated in the cross-sectional pilot study. The mean length of practice as specialists was 9.7 (± 7.8) years. The majority, 33 (89.2%), were males; 23 (62.2%) were ≤ 45 years of age, and 14 (37.8%) had practiced as consultant pediatric surgeons for ≥ 10 years.

When presented with a patient with anorectal malformation and recto-bladder neck fistula or Hirschsprung disease who developed fecal incontinence after surgery, 25 (67.6%) and 22 (59.5%), respectively, will combine modalities in managing the patient. Bowel management (81.1% and 83.8% respectively) was the most commonly selected option of managing postoperative fecal incontinence. Other options selected for the management of postoperative fecal incontinence were as follows: examination under anesthesia (43.2% and 37.8%), constipating diet (43.2% and 35.1%), re-operation (24.3% and 27.0%), and diverting colostomy (21.6% and 16.2%) for anorectal malformation and Hirschsprung disease respectively. There were no statistically significant associations between the length of practice as specialist pediatric surgeons and the selection of single vs. multiple treatment options for a patient with fecal incontinence after surgery either for anorectal malformation or Hirschsprung disease.

Conclusions

A combination of modalities will be adopted by at least 60% of pediatric surgeons in Nigeria to manage postoperative pediatric fecal incontinence with bowel management favored by over 80% of specialists surveyed.