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Bokova E, Elhalaby I, Svetanoff WJ, Lawal TA, Levitt MA, Lim IIP, Rentea RM. Global Strategies for Postoperative Care and Bowel Management in Patients With Anorectal Malformations: Varied Practices and Barriers. J Pediatr Surg 2024:161697. [PMID: 39256064 DOI: 10.1016/j.jpedsurg.2024.161697] [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: 05/01/2024] [Revised: 08/14/2024] [Accepted: 08/14/2024] [Indexed: 09/12/2024]
Abstract
BACKGROUND Anorectal malformations (ARMs) commonly result in constipation and fecal incontinence following primary surgical reconstruction. This study investigates global variations in postoperative care and resources. METHODS A survey was distributed via the International Pediatric Endosurgery Group (IPEG) and snowball sampling. Geographically, respondents were categorized into high-income countries (HICs) and low-or middle-income countries (LMICs). RESULTS 233 surveys were received, 64% from LMICs and 36% from HICs. Of these, 51% reported monitoring ARM patients for over a year, while 23% utilized digital technologies. Access to anesthesia for anorectal exams was available to 70% of respondents. Only 29% had established a one-week Bowel Management Program (BMP). Collaboration with urologists and gynecologists was more prevalent in HICs (59%) compared to LMICs (37%, p < 0.01). In HICs, nurses and advanced practice providers were significantly more involved in BMP (71% vs. 39% in LMICs; p < 0.01), and abdominal radiographs for regimen adjustments were used more frequently (80% vs. 69% in LMICs; p = 0.03). Treatment regimens were more varied in HICs, and quality of life tracking was more consistent (19% vs. 9% in LMICs; p = 0.02). LMICs reported significant shortages of medications and equipment (75% vs. 58% in HICs; p = 0.01), inadequate sanitation (48% vs. 24%; p < 0.01), and insufficient insurance coverage (58% vs. 44%; p = 0.04). CONCLUSIONS There are notable global disparities in the postoperative care of ARM patients, particularly in BMP protocols and treatment regimens, with LMICs facing severe socioeconomic challenges. This emphasizes the urgent need for targeted strategies and resources to enhance outcomes for ARM patients across different regions. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Elizaveta Bokova
- Comprehensive Colorectal Center, Section of Colorectal and Pelvic Reconstructive Surgery, Department of Pediatric Surgery, Children's Mercy Kansas City, Kansas City, MO, 64108, USA
| | - Ismael Elhalaby
- Comprehensive Colorectal Center, Section of Colorectal and Pelvic Reconstructive Surgery, Department of Pediatric Surgery, Children's Mercy Kansas City, Kansas City, MO, 64108, USA; Tanta University Hospital, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Wendy Jo Svetanoff
- Comprehensive Colorectal Center, Section of Colorectal and Pelvic Reconstructive Surgery, Department of Pediatric Surgery, Children's Mercy Kansas City, Kansas City, MO, 64108, USA
| | - Taiwo A Lawal
- Division of Pediatric Surgery, University College Hospital and Department of Surgery, University of Ibadan, Ibadan, Nigeria
| | - Marc A Levitt
- Division of Colorectal and Pelvic Reconstruction, Children's National Medical Center, Washington, DC, 20001, USA
| | - Irene Isabel P Lim
- Comprehensive Colorectal Center, Section of Colorectal and Pelvic Reconstructive Surgery, Department of Pediatric Surgery, Children's Mercy Kansas City, Kansas City, MO, 64108, USA; Department of Surgery, University of Missouri-Kansas City, Kansas City, MO 64108, USA
| | - Rebecca M Rentea
- Comprehensive Colorectal Center, Section of Colorectal and Pelvic Reconstructive Surgery, Department of Pediatric Surgery, Children's Mercy Kansas City, Kansas City, MO, 64108, USA; Department of Surgery, University of Missouri-Kansas City, Kansas City, MO 64108, USA.
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Lim IIP, Rentea RM. Bridging the Gap: The Impact of Bowel Management Programs on Daily Life in Pediatric Colorectal Disease. J Pediatr Surg 2024:S0022-3468(24)00419-6. [PMID: 39089895 DOI: 10.1016/j.jpedsurg.2024.07.009] [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: 07/08/2024] [Accepted: 07/10/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND This commentary discusses the social impact of bowel management programs (BMPs) on children with colorectal diseases, including anorectal malformations (ARM), Hirschsprung disease (HD), functional constipation (FC), and spina bifida. Previous studies focused on functional outcomes, but this study bridges the gap to daily life experiences. METHODS The study examined children's experiences in BMPs, focusing on school participation, vacation ability, and overall patient experience. Cleanliness, defined as fewer than one stool soiling episode per week, was achieved by 70% of participants. RESULTS Positive patient experiences were linked to achieving stool cleanliness, regardless of the management method. Invasive methods like enemas did not negatively affect experiences if cleanliness was maintained. Validated patient-reported experience measures (PREMs) and patient-reported outcomes measures (PROMs) were used, though the median age of 8.9 years posed limitations. CONCLUSION The commentary highlights the significance of stool cleanliness in improving patient experiences and supports the effectiveness of various BMP methods. Future research should include longitudinal follow-ups to assess BMP durability and gather data from older children.
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Affiliation(s)
- Irene Isabel P Lim
- Comprehensive Colorectal Center, Section of Colorectal and Pelvic Reconstructive Surgery, Department of Pediatric Surgery, Children's Mercy-Kansas City, Kansas City, MO, 64108, USA; University of Missouri- Kansas City, Kansas City, MO, 64108, USA
| | - Rebecca M Rentea
- Comprehensive Colorectal Center, Section of Colorectal and Pelvic Reconstructive Surgery, Department of Pediatric Surgery, Children's Mercy-Kansas City, Kansas City, MO, 64108, USA; University of Missouri- Kansas City, Kansas City, MO, 64108, USA.
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3
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Ambartsumyan L. Medical management of anorectal malformations. Aliment Pharmacol Ther 2024; 60 Suppl 1:S77-S84. [PMID: 38924569 DOI: 10.1111/apt.17897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 11/28/2023] [Accepted: 01/26/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Anorectal malformations (ARMs) are congenital anomalies of the anorectum and the genitourinary system that result in a broad spectrum of hindgut anomalies. Despite surgical correction patients continue to have late postoperative genitourinary and colorectal dysfunction that have significant impact on quality of life. AIM This paper will review the current evidence and discuss the evaluation and management of postoperative patients with ARMs who present with persistent defecation disorder. METHODS A literature search was conducted using PubMed/MEDLINE/EMBASE databases applying the following terms: ARMs, imperforate anus, constipation, faecal incontinence, neurogenic bowel, posterior sagittal anorectoplasty. RESULTS Patients who present with postoperative defecation disorders require timely diagnostic and surgical evaluation for anatomic abnormalities prior to initiation of bowel management. Goals of management are to avoid constipation in young children, achieve faecal continence in early childhood and facilitate independence in older children and adolescents. Treatment options vary from high dose stimulant laxatives to high-volume retrograde and antegrade enemas that facilitate mechanical colonic emptying. CONCLUSIONS Appropriate diagnostic work-up and implementation of treatment can decrease long-term morbidity and improve quality of life in postoperative patients with ARMs who presents with defecation disorders.
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Affiliation(s)
- Lusine Ambartsumyan
- Division of Gastroenterology and Nutrition, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington, USA
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Dougherty D, Ralls MW, Plagens CJ, Ladino-Torres M, Williams KM, Wild L, Jarboe MD. Functional Outcomes of Patients Who Underwent Anorectal Malformation Repair Using MRI Guidance. J Pediatr Surg 2024; 59:1044-1049. [PMID: 38195357 DOI: 10.1016/j.jpedsurg.2023.12.023] [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: 08/28/2023] [Revised: 12/16/2023] [Accepted: 12/28/2023] [Indexed: 01/11/2024]
Abstract
BACKGROUND Despite the initiation of minimally invasive laparoscopic techniques, the majority of patients who undergo anorectal malformation repair still experience functional bowel issues in childhood, including constipation and fecal incontinence. In this study, we evaluate the functional outcomes of a procedure in which magnetic resonance imaging guidance is used during initial laparoscopic repair to better locate the epicenter of the sphincter muscle complex and pelvic floor with the goal of more accurate placement of the neoanus and improved functional outcomes. METHODS A retrospective chart review evaluated demographic, operative, and outcome details for patients who underwent this procedure. A telephone survey was employed to determine levels of social continence using the validated Baylor Continence Scale and to determine what type of bowel management is used. RESULTS Twenty-six patients were included. Median age at operation was 7 months, and median age at follow-up was 4 years old, with a range of 1-9. Bowel management regimen results revealed that 19 % (n = 5) use no bowel management regimen, 58 % (n = 15) use laxatives only, and 23 % (n = 6) use enemas. Enema use was not associated with different spine or sacral anomalies (p = 0.77). Fifteen patients (58 %) answered the Baylor Continence Scale questions and had a median score of 14. No difference was found in scores when accounting for lesion level (p = 0.43), quality of needle placement (p = 0.46), or quality of sphincter muscles (p = 0.75). CONCLUSIONS Using MRI guidance in the repair of anorectal malformations shows promise in both the qualitative and quantitative functional outcomes of this complex patient population. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Danielle Dougherty
- University of Michigan, Michigan Medicine, Department of Surgery, Section of Pediatric Surgery, C.S. Mott Children's Hospital, 1540 E. Hospital Dr., Ann Arbor, MI 48109-4211, United States; Connecticut Children's Hospital, Department of Surgery, Section of Pediatric Surgery, 282 Washington Street, Hartford, CT 06106, United States
| | - Matthew W Ralls
- University of Michigan, Michigan Medicine, Department of Surgery, Section of Pediatric Surgery, C.S. Mott Children's Hospital, 1540 E. Hospital Dr., Ann Arbor, MI 48109-4211, United States; Nationwide Children's Hospital - Toledo, Department of Surgery, Section of Pediatric Surgery, Mercy Health - St. Vincent Medical Center, 2222 Cherry St., Suite 1800, Toledo, OH 43608, United States
| | - Connor J Plagens
- University of Michigan, Michigan Medicine, Department of Surgery, Section of Pediatric Surgery, C.S. Mott Children's Hospital, 1540 E. Hospital Dr., Ann Arbor, MI 48109-4211, United States
| | - Maria Ladino-Torres
- University of Michigan, Michigan Medicine, Department of Radiology, C.S. Mott Children's Hospital, 1540 E. Hospital Dr., Ann Arbor, MI 48109-4211, United States
| | - Keyonna M Williams
- University of Michigan, Michigan Medicine, Department of Surgery, Section of Pediatric Surgery, C.S. Mott Children's Hospital, 1540 E. Hospital Dr., Ann Arbor, MI 48109-4211, United States
| | - Laurie Wild
- University of Michigan, Michigan Medicine, Department of Surgery, Section of Pediatric Surgery, C.S. Mott Children's Hospital, 1540 E. Hospital Dr., Ann Arbor, MI 48109-4211, United States
| | - Marcus D Jarboe
- University of Michigan, Michigan Medicine, Department of Surgery, Section of Pediatric Surgery, C.S. Mott Children's Hospital, 1540 E. Hospital Dr., Ann Arbor, MI 48109-4211, United States; Nationwide Children's Hospital - Toledo, Department of Surgery, Section of Pediatric Surgery, Mercy Health - St. Vincent Medical Center, 2222 Cherry St., Suite 1800, Toledo, OH 43608, United States.
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Highet A, Mai T, Klarich MK, Vu L. Neighborhood-level Disparities in Achievement of Social Continence Among School-aged Children With Anorectal Malformations: A Single-center Retrospective Study. J Pediatr Surg 2024:S0022-3468(24)00315-4. [PMID: 38897896 DOI: 10.1016/j.jpedsurg.2024.05.013] [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: 02/14/2024] [Revised: 05/01/2024] [Accepted: 05/22/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND Fecal incontinence is a common problem for children with repaired anorectal malformations (ARM) and has significant implications for initiating school. While sex, anatomy, and medical comorbidities are known to influence continence outcomes, the impact of socioeconomic factors and neighborhood-level disadvantage are less well understood. METHODS We performed a single-center retrospective review of all school-aged (5-18 years) children with ARM at a longitudinal pediatric surgery clinic. Demographic, clinical, and socioeconomic variables were abstracted via chart review and geocoding was performed to obtain Area Deprivation Index (ADI) and Social Vulnerability Index (SVI) scores. Statistical analyses assessed for associations between the primary outcome of social continence (defined as no diaper usage and infrequent fecal accidents at age 5) and these variables. RESULTS 72 patients were included; of these, 45.8% were socially continent. On bivariate analysis, social continence was significantly associated with state ADI score as well as the SVI Housing characteristics score. These associations remained significant when adjusting for sex and medical comorbidities in separate multiple logistic regression models. CONCLUSION The relative disadvantage of the neighborhood in which a child with ARM lives may play a role in their ability to achieve continence by school age. Efforts are warranted to identify and develop targeted interventions to for this pediatric population. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Alexandra Highet
- University of California San Francisco, Department of Surgery, San Francisco, CA, USA.
| | - Tina Mai
- University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Mary-Kate Klarich
- University of California San Francisco Benioff Children's Hospital San Francisco, San Francisco, CA, USA
| | - Lan Vu
- University of California San Francisco, Department of Surgery, San Francisco, CA, USA; University of California San Francisco Benioff Children's Hospital San Francisco, San Francisco, CA, USA
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Srinivas S, Scheiber AJ, Ahmad H, Thomas J, Weaver L, Wood RJ, Hewitt G, McCracken K. Examining Results of Post-Thelarche Screening Pelvic Ultrasound in Females with Anorectal Malformations. J Pediatr Adolesc Gynecol 2024:S1083-3188(24)00228-6. [PMID: 38768703 DOI: 10.1016/j.jpag.2024.05.001] [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: 01/12/2024] [Revised: 05/08/2024] [Accepted: 05/15/2024] [Indexed: 05/22/2024]
Abstract
STUDY OBJECTIVE Mullerian duct anomalies are common in females with anorectal malformations (ARMs), although there are no universally recommended screening protocols for identification. Historically, at our institution, we have recommended a screening pelvic ultrasound (PUS) 6 months after thelarche and menarche. We aimed to evaluate outcomes associated with our post-thelarche screening PUS in females with ARMs. METHODS An institutional review board-approved retrospective chart review was performed for all female patients 8 years old or older with ARMs and documented thelarche. Data were collected on demographic characteristics and clinical course. The primary outcome was adherence to the recommended PUS. Secondary outcomes included imaging correlation with suspected Mullerian anatomy and need for intervention on the basis of imaging findings. RESULTS A total of 112 patients met the inclusion criteria. Of them, 87 (77.7%) completed a recommended post-thelarche screening PUS. There were no differences in completion on the basis of age, race, establishment with a primary care provider, insurance status, or type of ARM. Nine patients (10.3%) had findings on their PUS that did not correlate with their suspected Mullerian anatomy; five (5.7%) required intervention, with two requiring menstrual suppression, two requiring surgical intervention, and one requiring further imaging. CONCLUSION Most patients completed the recommended post-thelarche screening PUS. In a small subset of patients, PUS did not correlate with suspected Mullerian anatomy and generated a need for intervention. Post-thelarche PUS can be a useful adjunct in patients with ARMs to identify gynecologic abnormalities.
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Affiliation(s)
- Shruthi Srinivas
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, Ohio.
| | | | - Hira Ahmad
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, Ohio
| | - Jessica Thomas
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, Ohio
| | - Laura Weaver
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, Ohio
| | - Richard J Wood
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, Ohio
| | - Geri Hewitt
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatric and Adolescent Gynecology, Nationwide Children's Hospital, Columbus, Ohio
| | - Kate McCracken
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatric and Adolescent Gynecology, Nationwide Children's Hospital, Columbus, Ohio
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Srinivas S, Gasior A, Driesbach S, DeBacco N, Pruitt LCC, Trimble C, Zahora P, Mueller CM, Wood RJ. Development of a Standardized Algorithm for Management of Newly Diagnosed Anorectal Malformations. CHILDREN (BASEL, SWITZERLAND) 2024; 11:494. [PMID: 38671711 PMCID: PMC11049553 DOI: 10.3390/children11040494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 04/08/2024] [Accepted: 04/19/2024] [Indexed: 04/28/2024]
Abstract
Neonates with a new diagnosis of anorectal malformation (ARM) present a unique challenge to the clinical team. ARM is strongly associated with additional midline malformations, such as those observed in the VACTERL sequence, including vertebral, cardiac, and renal malformations. Timely assessment is necessary to identify anomalies requiring intervention and to prevent undue stress and delayed treatment. We utilized a multidisciplinary team to develop an algorithm guiding the midline workup of patients newly diagnosed with ARM. Patients were included if born in or transferred to our neonatal intensive care unit (NICU), or if seen in clinic within one month of life. Complete imaging was defined as an echocardiogram, renal ultrasound, and spinal magnetic resonance imaging or ultrasound within the first month of life. We compared three periods: prior to implementation (2010-2014), adoption period (2015), and delayed implementation (2022); p ≤ 0.05 was considered significant. Rates of complete imaging significantly improved from pre-implementation to delayed implementation (65.2% vs. 50.0% vs. 97.0%, p = 0.0003); the most growth was observed in spinal imaging (71.0% vs. 90.0% vs. 100.0%, p = 0.001). While there were no differences in the rates of identified anomalies, there were fewer missed diagnoses with the algorithm (10.0% vs. 47.6%, p = 0.05). We demonstrate that the implementation of a standardized algorithm can significantly increase appropriate screening for anomalies associated with a new diagnosis of ARM and can decrease delayed diagnosis. Further qualitative studies will help to refine and optimize the algorithm moving forward.
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Affiliation(s)
- Shruthi Srinivas
- Department of Colorectal and Pelvic Reconstructive Surgery, Nationwide Children’s Hospital, 611 E. Livingston Ave., Columbus, OH 43205, USA
- Department of Pediatric Surgery, Nationwide Children’s Hospital, Columbus, OH 43205, USA
| | - Alessandra Gasior
- Department of Colorectal and Pelvic Reconstructive Surgery, Nationwide Children’s Hospital, 611 E. Livingston Ave., Columbus, OH 43205, USA
| | - Sarah Driesbach
- Department of Colorectal and Pelvic Reconstructive Surgery, Nationwide Children’s Hospital, 611 E. Livingston Ave., Columbus, OH 43205, USA
| | - Natalie DeBacco
- Department of Colorectal and Pelvic Reconstructive Surgery, Nationwide Children’s Hospital, 611 E. Livingston Ave., Columbus, OH 43205, USA
| | - Liese C. C. Pruitt
- Department of Colorectal and Pelvic Reconstructive Surgery, Nationwide Children’s Hospital, 611 E. Livingston Ave., Columbus, OH 43205, USA
- Department of Pediatric Surgery, Nationwide Children’s Hospital, Columbus, OH 43205, USA
| | - Casey Trimble
- Department of Colorectal and Pelvic Reconstructive Surgery, Nationwide Children’s Hospital, 611 E. Livingston Ave., Columbus, OH 43205, USA
| | - Pooja Zahora
- Department of Colorectal and Pelvic Reconstructive Surgery, Nationwide Children’s Hospital, 611 E. Livingston Ave., Columbus, OH 43205, USA
| | - Claudia M. Mueller
- Department of Pediatric Surgery, Stanford Children’s Hospital, Stanford, CA 94304, USA
| | - Richard J. Wood
- Department of Colorectal and Pelvic Reconstructive Surgery, Nationwide Children’s Hospital, 611 E. Livingston Ave., Columbus, OH 43205, USA
- Department of Pediatric Surgery, Nationwide Children’s Hospital, Columbus, OH 43205, USA
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Chua ME, Silangcruz JM, Kim JK, Koyle MA, Sriharan A. A Scoping Review on Learning Health Networks Available in Pediatric Surgical Specialties. J Pediatr Surg 2023; 58:2416-2428. [PMID: 37544802 DOI: 10.1016/j.jpedsurg.2023.07.006] [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: 01/03/2023] [Revised: 07/10/2023] [Accepted: 07/10/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND Learning health networks (LHN) are consortia of institutions that collaborate and embrace the elements of the learning health system (LHS), including quality improvement, education, research, and stakeholder involvement. Their ultimate goal is rapid information dissemination in clinical care. Pediatric surgical specialties perform unique yet high-impact procedures that could benefit from LHN, thereby improving surgical outcomes and care through LHS approaches. Consequently, health system leaders should be aware of LHN and their importance in enhancing surgical care and improving outcomes. This scoping review aims to map and characterize the existing LHN applied in pediatric surgical specialties. METHODS A systematic literature search was performed on Medline, EMBASE, and Scopus up to June 2022, with an update search conducted in May 2023. Additionally, Google Scholar, ProQuest and inquiry from topic experts were used for cross-referencing relevant review articles to identify grey literature. This scoping review was conducted and reported according to the PRISMA-scoping review extension. RESULTS A total of 56 publications for 19 LHN were identified and included in this scoping review. Out of 19 identified LHN in pediatric surgical specialties, 18 were organized in North America. Eight of the networks are related to pediatric general surgery and another eight were related to pediatric transplantation. The 16 out of 19 LHN were initiated after 2001. To date, only eight of the LHNs generated reports of comparative improved outcomes. CONCLUSION This scoping review provides an overview of the available LHNs in pediatric surgical specialties. Over the past decade, several pediatric surgical specialties have embraced the principles of learning health systems, forming inter-institutional collaborations that utilize information technology to generate big data on patient-level clinical information, engage in quality improvement cycles, adopt evidence-based practices, and actively involve patients and stakeholders. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Michael E Chua
- Global Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada; Division of Urology, Department of Surgery, The Hospital for Sick Children, Toronto, ON, Canada; Institute of Urology, St. Luke's Medical Center, Quezon City, NCR, Philippines.
| | | | - Jin Kyu Kim
- Department of Surgery, Faculty of Medicine and Surgery, University of Toronto, ON, Canada
| | - Martin A Koyle
- System Leadership and Innovation, Institute of Health Policy, Management and Evaluation, University of Toronto, ON, Canada
| | - Abi Sriharan
- System Leadership and Innovation, Institute of Health Policy, Management and Evaluation, University of Toronto, ON, Canada
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Ye S, Feng W, Zhou Y, Ming A, Chen M, Yang C, Zheng C, Gao R, Diao M, Wang Y, Li L. Laparoscopic-assisted anorectoplasty for anorectal malformation with rectobulbar fistula: A two-center comparative study with posterior sagittal anorectoplasty. Medicine (Baltimore) 2023; 102:e35825. [PMID: 37986398 PMCID: PMC10659725 DOI: 10.1097/md.0000000000035825] [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: 09/23/2023] [Revised: 10/05/2023] [Accepted: 10/06/2023] [Indexed: 11/22/2023] Open
Abstract
Due to the controversy on the feasibility of laparoscopic-assisted anorectoplasty (LAARP) for the treatment of the anorectal malformation (ARM) with rectobulbar fistula (RBF), this study aimed to compare the outcomes of LAARP and posterior sagittal anorectoplasty (PSARP) for ARM with RBF. Demographic data, postoperative complications, and bowel function of RBF patients who underwent LAARP and PSARP at 2 medical centers from 2016-2018 were retrospectively reviewed. Eighty-eight children with RBF were enrolled, including 43 in the LAARP group and 45 in the PSARP group. There were no significant differences in the sacral ratio (P = .222) or sacral agenesis (P = .374). Thirty-seven and 38 patients in the LAARP and PSARP groups were followed up for a median of 4.14 years. The postoperative complications were comparable between the groups (P = .624), with no cases of urethral diverticulum. The urination of all cases was normal and no evidence of cyst formation was found on MCU or MRI during the follow-up period. The incidence of rectal prolapse was similar between the 2 groups (9.3% vs 17.8%, P = .247). The groups had equivalent Bowel Function Score (15.29 ± 2.36 vs 15.58 ± 2.88, P = .645), but the LAARP group had better voluntary bowel movement (94.6% vs 84.2%, P = .148) by Krickenbeck classification. The intermediate-term outcomes of LAARP show that the urethral diverticulum was rare by the intraluminal incision of the fistular and the bowel function was comparable to that of PSARP in ARM with rectobulbar fistula. However, LAARP was associated with smaller perineal wounds.
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Affiliation(s)
- Shiru Ye
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, People’s Republic of China
| | - Wei Feng
- Department of General & Neonatal Surgery, Children’s Hospital of Chongqing Medical University; National Clinical Research Center for Child Health and Disorders; Ministry of Education Key Laboratory of Child Development and Disorders; Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Yan Zhou
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, People’s Republic of China
| | - Anxiao Ming
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, People’s Republic of China
| | - Minming Chen
- Department of General & Neonatal Surgery, Children’s Hospital of Chongqing Medical University; National Clinical Research Center for Child Health and Disorders; Ministry of Education Key Laboratory of Child Development and Disorders; Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Changzhen Yang
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, People’s Republic of China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
- Research Unit of Minimally Invasive Pediatric Surgery on Diagnosis and Treatment(2021RU015), Chinese Academy of Medical Sciences, Beijing, China
| | - Chen Zheng
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, People’s Republic of China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
- Research Unit of Minimally Invasive Pediatric Surgery on Diagnosis and Treatment(2021RU015), Chinese Academy of Medical Sciences, Beijing, China
| | - Ruyue Gao
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, People’s Republic of China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
- Research Unit of Minimally Invasive Pediatric Surgery on Diagnosis and Treatment(2021RU015), Chinese Academy of Medical Sciences, Beijing, China
| | - Mei Diao
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, People’s Republic of China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
- Research Unit of Minimally Invasive Pediatric Surgery on Diagnosis and Treatment(2021RU015), Chinese Academy of Medical Sciences, Beijing, China
| | - Yi Wang
- Department of General & Neonatal Surgery, Children’s Hospital of Chongqing Medical University; National Clinical Research Center for Child Health and Disorders; Ministry of Education Key Laboratory of Child Development and Disorders; Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Long Li
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, People’s Republic of China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
- Research Unit of Minimally Invasive Pediatric Surgery on Diagnosis and Treatment(2021RU015), Chinese Academy of Medical Sciences, Beijing, China
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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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Bokova E, Svetanoff WJ, Lopez JJ, Levitt MA, Rentea RM. State of the Art Bowel Management for Pediatric Colorectal Problems: Anorectal Malformations. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10050846. [PMID: 37238394 DOI: 10.3390/children10050846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/28/2023] [Accepted: 05/04/2023] [Indexed: 05/28/2023]
Abstract
Up to 79% of patients with anorectal malformations (ARMs) experience constipation and/or soiling after a primary posterior sagittal anoplasty (PSARP) and are referred to a bowel management program. We aim to report the recent updates in evaluating and managing these patients as part of the manuscript series on the current bowel management protocols for patients with colorectal diseases (ARMs, Hirschsprung disease, functional constipation, and spinal anomalies). The unique anatomic features of ARM patients, such as maldeveloped sphincter complex, impaired anal sensation, and associated spine and sacrum anomalies, indicate their bowel management plan. The evaluation includes an examination under anesthesia and a contrast study to exclude anatomic causes of poor bowel function. The potential for bowel control is discussed with the families based on the ARM index calculated from the quality of the spine and sacrum. The bowel management options include laxatives, rectal enemas, transanal irrigations, and antegrade continence enemas. In ARM patients, stool softeners should be avoided as they can worsen soiling.
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Affiliation(s)
- Elizaveta Bokova
- Comprehensive Colorectal Center, Department of Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA
| | - Wendy Jo Svetanoff
- Comprehensive Colorectal Center, Department of Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA
| | - Joseph J Lopez
- Comprehensive Colorectal Center, Department of Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA
| | - Marc A Levitt
- Division of Colorectal and Pelvic Reconstruction, Children's National Medical Center, Washington, DC 20001, USA
| | - Rebecca M Rentea
- Comprehensive Colorectal Center, Department of Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA
- Department of Surgery, University of Missouri-Kansas City, Kansas City, MO 64108, USA
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12
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Iantorno SE, Rollins MD, Austin K, Avansino JR, Badillo A, Calkins CM, Crady RC, Dickie BH, Durham MM, Frischer JS, Fuller MK, Grabowski JE, Ralls MW, Reeder RW, Rentea RM, Saadai P, Wood RJ, van Leeuwen KD, Short SS. Rectal Prolapse Following Repair of Anorectal Malformation: Incidence, Risk Factors, and Management. J Pediatr Surg 2023:S0022-3468(23)00252-X. [PMID: 37173214 DOI: 10.1016/j.jpedsurg.2023.04.010] [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: 05/15/2023]
Abstract
BACKGROUND The incidence and optimal management of rectal prolapse following repair of an anorectal malformation (ARM) has not been well-defined. METHODS A retrospective cohort study was performed utilizing data from the Pediatric Colorectal and Pelvic Learning Consortium registry. All children with a history of ARM repair were included. Our primary outcome was rectal prolapse. Secondary outcomes included operative management of prolapse and anoplasty stricture following operative management of prolapse. Univariate analyses were performed to identify patient factors associated with our primary and secondary outcomes. A multivariable logistic regression was developed to assess the association between laparoscopic ARM repair and rectal prolapse. RESULTS A total of 1140 patients met inclusion criteria; 163 (14.3%) developed rectal prolapse. On univariate analysis, prolapse was significantly associated with male sex, sacral abnormalities, ARM type, ARM complexity, and laparoscopic ARM repairs (p < 0.001). ARM types with the highest rates of prolapse included rectourethral-prostatic fistula (29.2%), rectovesical/bladder neck fistula (28.8%), and cloaca (25.0%). Of those who developed prolapse, 110 (67.5%) underwent operative management. Anoplasty strictures developed in 27 (24.5%) patients after prolapse repair. After controlling for ARM type and hospital, laparoscopic ARM repair was not significantly associated with prolapse (adjusted odds ratio (95% CI): 1.50 (0.84, 2.66), p = 0.17). CONCLUSION Rectal prolapse develops in a significant subset of patients following ARM repair. Risk factors for prolapse include male sex, complex ARM type, and sacral abnormalities. Further research investigating the indications for operative management of prolapse and operative techniques for prolapse repair are needed to define optimal treatment. TYPE OF STUDY Retrospective cohort study. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Stephanie E Iantorno
- Department of Surgery, Primary Children's Hospital, University of Utah, Salt Lake City, UT, USA.
| | - Michael D Rollins
- Department of Surgery, Primary Children's Hospital, University of Utah, Salt Lake City, UT, USA
| | - Kelly Austin
- Department of Surgery, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jeffrey R Avansino
- Department of Surgery, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Andrea Badillo
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, George Washington University, Washington, DC, USA
| | - Casey M Calkins
- Department of Surgery, Children's Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Rachel C Crady
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Belinda H Dickie
- Department of Surgery, Boston Children's Hospital, Harvard University, Boston, MA, USA
| | - Megan M Durham
- Emory + Children's Pediatric Institute, Atlanta, GA, USA
| | - Jason S Frischer
- Department of Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Megan K Fuller
- Department of Surgery, Boys Town Research Hospital-Children's of Omaha, University of Nebraska Medical Center, Boys Town, NE, USA
| | - Julia E Grabowski
- Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, IL, USA
| | - Matthew W Ralls
- Department of Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Rebecca M Rentea
- Department of Surgery, Children's Mercy Hospital, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Payam Saadai
- Department of Surgery, UC Davis Children's Hospital, University of California Davis, Davis, CA, USA
| | - Richard J Wood
- Department of Surgery, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Kathleen D van Leeuwen
- Department of Surgery, Phoenix Children's Hospital, University of Arizona, Phoenix, AZ, USA
| | - Scott S Short
- Department of Surgery, Primary Children's Hospital, University of Utah, Salt Lake City, UT, USA
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13
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Bokova E, Svetanoff WJ, Levitt MA, Rentea RM. Pediatric Bowel Management Options and Organizational Aspects. CHILDREN 2023; 10:children10040633. [PMID: 37189882 DOI: 10.3390/children10040633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 03/20/2023] [Accepted: 03/22/2023] [Indexed: 03/30/2023]
Abstract
A bowel management program (BMP) to treat fecal incontinence and severe constipation is utilized for patients with anorectal malformations, Hirschsprung disease, spinal anomalies, and functional constipation, decreasing the rate of emergency department visits, and hospital admissions. This review is part of a manuscript series and focuses on updates in the use of antegrade flushes for bowel management, as well as organizational aspects, collaborative approach, telemedicine, the importance of family education, and one-year outcomes of the bowel management program. Implementation of a multidisciplinary program involving physicians, nurses, advanced practice providers, coordinators, psychologists, and social workers leads to rapid center growth and enhances surgical referrals. Education of the families is crucial for postoperative outcomes, prevention, and early detection of complications, especially Hirschsprung-associated enterocolitis. Telemedicine can be proposed to patients with a defined anatomy and is associated with high parent satisfaction and decreased patient stress in comparison to in-person visits. The BMP has proved to be effective in all groups of colorectal patients at a 1- and 2-year follow-up with social continence achieved in 70–72% and 78% of patients, respectively, and an improvement in the patients’ quality of life. A transitional care to adult program is essential to maintain the same quality of care, and continuity of care and to achieve desired long-term outcomes as the patient reaches adult age.
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Chanchlani R, Budhwani KS. A Study of the Clinical Profile and Management of Children With Anorectal Malformations. Cureus 2023; 15:e36772. [PMID: 37123807 PMCID: PMC10145631 DOI: 10.7759/cureus.36772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 03/27/2023] [Indexed: 03/30/2023] Open
Abstract
Introduction The diagnosis of anorectal malformations (ARMs) antenatally is rare, and most of these cases are diagnosed in the neonatal period. The defects range from easily treated minor anomalies with good prognosis to those that are difficult and complex. The associated anomalies in these malformations are important determinants for the prognosis and outcome of these cases. Material and methods The present study was carried out in the department of pediatric surgery in a tertiary care institute. Patients presenting with ARMs in the neonatal period, those reported for definitive surgery, and patients for colostomy closure surgery were included. Patients who died before surgical treatment were excluded from the study. Convenience sampling of 100 patients who met the inclusion criteria was performed until the sample size was reached. Results Out of 63 cases of high variety, 84.12% were males and 15.87% were females. Out of 37 patients of low variety, 43.24% were males and 56.75% were females. The anomalies of the urogenital system were present in 22 (34.92%) out of 63 cases of high ARMs and 10 (27.02%) out of 37 cases of low ARMs. In the male patients, anocutaneous fistula was in 16 (23.18%) of cases. Out of 31 females in the present study, anorectal agenesis with anovestibular fistula was seen in 19 (61.29%) cases. In the early complications, significant bleeding and urethral injury were seen in one (2.63%) patient each. However, among the late complications, anal stenosis, mucosal prolapse, and wound infection were seen in seven (18.42%), five (13.15%), and four (10.52%) patients, respectively. Conclusion A holistic approach to the management of ARMs is needed with a long-term goal of achieving urinary and fecal continence with good quality of life. The outcome of surgery is dependent on the specific type of malformation, but the results are better when intervention is done early.
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15
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Feng W, Mu H, Chen M, Zhu J, Xiang C, Fan L, Hou J, Die X, Wang Y. Significance of searching for ganglia in the terminal rectum/fistula of complex anorectal malformations: Related to defecation function. Front Pediatr 2023; 11:1124647. [PMID: 36911041 PMCID: PMC10003345 DOI: 10.3389/fped.2023.1124647] [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: 12/15/2022] [Accepted: 01/31/2023] [Indexed: 02/24/2023] Open
Abstract
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.
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Affiliation(s)
- Wei Feng
- Department of General and Neonatal Surgery, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Huaqi Mu
- Department of General and Neonatal Surgery, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Minmin Chen
- Department of General and Neonatal Surgery, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Jin Zhu
- Department of Pathology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Chenzhu Xiang
- Department of General and Neonatal Surgery, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Linxiao Fan
- Department of General and Neonatal Surgery, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Jinping Hou
- Department of General and Neonatal Surgery, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Xiaohong Die
- Department of General and Neonatal Surgery, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Yi Wang
- Department of General and Neonatal Surgery, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
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Svetanoff WJ, Lawson A, Lopez JJ, Briggs KB, Fraser JA, Kapalu CL, Gatti J, Priebe AM, Strickland J, Rentea RM. Unique Evaluation and Management Considerations for Adolescents with Late Gynecologic and Colorectal Issues in the Setting of Anorectal Malformations. J Pediatr Adolesc Gynecol 2022; 36:315-320. [PMID: 36535338 DOI: 10.1016/j.jpag.2022.12.002] [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: 07/21/2022] [Revised: 10/31/2022] [Accepted: 12/11/2022] [Indexed: 12/23/2022]
Abstract
STUDY OBJECTIVE There is little guidance for managing pubertally identified Mullerian anomalies in patients with anorectal malformations (ARMs). We sought to assess these unique issues. DESIGN Retrospective review SETTING: Single-institution study PARTICIPANTS: Natal female patients aged 10-25, with an ARM, cloaca, or exstrophy, who presented from 2009 to 2019 with a gynecologic concern were included. INTERVENTION Data collection was performed and included the presenting problem, psychological evaluation, fertility and sexuality concerns, and management strategies for these problems. MAIN OUTCOME MEASURES The main outcome was unique needs that had to be addressed in the young adult population and the type of colorectal and gynecological procedures needed on representation. RESULTS Twelve patients were identified; all had gynecologic concerns. Ten had ARMs, including cloaca (n = 3) and cloacal exstrophy (n = 5). Median age at representation was 14.6 years (IQR = 12.7, 15.3). Colorectal revisions included posterior sagittal anorectoplasty (n = 1), resection of bowel attached to urogenital sinus (n = 1), and appendicostomy revision (n = 1). Gynecologic issues included dysmenorrhea (n = 8), obstructed Mullerian anomaly (n = 6), and introital stenosis (n = 5). Behavioral health concerns (n = 9) and fertility/sexuality concerns (n = 4) were identified. Median time from first visit to reconstruction was 1.5 years (IQR = 0.5, 1.5), providing multiple visits to achieve consensus among patients and providers before intervention, including vaginal or introital repair (n = 5) and hysterectomy of obstructed uterine horns (n = 3). CONCLUSIONS Goal-directed follow-up is required before surgical management to identify psychological and reproductive issues in patients with ARMs who have gynecologic concerns. Patient input and psychologic consultation are helpful for patients requiring staged reconstruction.
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Affiliation(s)
- Wendy Jo Svetanoff
- Department of Surgery, Comprehensive Colorectal Center, Children's Mercy Kansas City, Kansas City, Missouri
| | - Ashli Lawson
- Department of Obstetrics and Gynecology, Children's Mercy Kansas City, Kansas City, Missouri
| | - Joseph J Lopez
- Department of Surgery, Comprehensive Colorectal Center, Children's Mercy Kansas City, Kansas City, Missouri
| | - Kayla B Briggs
- Department of Surgery, Comprehensive Colorectal Center, Children's Mercy Kansas City, Kansas City, Missouri
| | - James A Fraser
- Department of Surgery, Comprehensive Colorectal Center, Children's Mercy Kansas City, Kansas City, Missouri
| | - Christina Low Kapalu
- Department of Gastroenterology, Hepatology, and Nutrition, Children's Mercy Kansas City, Kansas City, Missouri; Department of Urology, Children's Mercy Kansas City, Kansas City, Missouri
| | - John Gatti
- Department of Urology, Children's Mercy Kansas City, Kansas City, Missouri; University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Anne-Marie Priebe
- Department of Obstetrics and Gynecology, Children's Mercy Kansas City, Kansas City, Missouri; University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Julie Strickland
- Department of Obstetrics and Gynecology, Children's Mercy Kansas City, Kansas City, Missouri; University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Rebecca M Rentea
- Department of Surgery, Comprehensive Colorectal Center, Children's Mercy Kansas City, Kansas City, Missouri; University of Missouri-Kansas City School of Medicine, Kansas City, Missouri.
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Short SS, Reeder RW, Lewis KE, Dickie B, Grabowski J, Sepuha T, Durham MM, Frischer J, Badillo A, Calkins CM, Rentea RM, Ralls M, Wood RJ, Fuller MK, van Leeuwen K, Avansino JR, Austin K, Rollins MD. The presence of a neurodiverse disorder is associated with increased use of antegrade enema therapy in children with severe constipation: A study from the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC). J Pediatr Surg 2022; 57:1676-1680. [PMID: 35597676 DOI: 10.1016/j.jpedsurg.2022.04.008] [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: 04/14/2022] [Accepted: 04/14/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Children with severe constipation and a neurodiverse disorder (Autism and/or developmental delay) represent a challenging bowel management group. Treatment outcomes with laxative or enema therapy remain limited and are often complicated by patient/caregiver compliance. We hypothesized that children with neurodiverse disorders and severe constipation would benefit from a bowel management program (BMP) that includes early use of antegrade enemas. MATERIALS AND METHODS Children requiring BMP in the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC) registry with diagnosis of constipation and/or constipation with pseudo-incontinence were reviewed. Those with Hirschsprung disease and/or Anorectal Malformation were excluded. BMP needs in patients with a neurodiverse diagnosis were compared to those without to evaluate differences in BMP's. RESULTS 372 patients requiring a BMP were identified. 95 patients (58 autism spectrum, 54 developmental delay) were neurodiverse, and 277 patients were not. Neurodiverse patients had a higher prevalence of enema therapy 62.1% (59/95) vs. 54.9% (152/273) and use of antegrade enema therapy 33.7% (32/95) vs. 21.2% (58/273), p = 0.126. Neurodiverse patients were older 37.9% (36/95) > 12 years vs. 23.1% (63/273), p = 0.001 and 47.6% (10/21) were changed from laxative to enema therapy over time. 80% (8/10) of those changed from laxatives to enemas used antegrade therapy. 67.3% (35/52) of neurodiverse patients followed over time were on enema therapy at the most recent visit with 80% (28/35) requiring antegrade therapy. CONCLUSION A large portion of patients with a neurodiverse disorder who fail laxative therapy use antegrade enemas to achieve effective bowel management. Early consideration of an antegrade conduit may simplify treatment in this group of children. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Scott S Short
- Primary Children's Hospital, 100 N. Mario Capecchi Drive, Suite 3800, Salt Lake City, UT 84108, USA.
| | | | | | | | | | | | | | | | | | | | | | - Matt Ralls
- C.S. Mott Children's Hospital/Univ. of Michigan, Ann Arbor, MI, USA
| | | | | | | | | | | | - Michael D Rollins
- Primary Children's Hospital, 100 N. Mario Capecchi Drive, Suite 3800, Salt Lake City, UT 84108, USA
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18
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Annual Pediatric Colorectal and Pelvic Learning Consortium (PCPLC) Scientific Meeting. J Pediatr Surg 2022; 57:1671. [PMID: 35597675 DOI: 10.1016/j.jpedsurg.2022.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 04/15/2022] [Indexed: 11/21/2022]
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Rollins MD, Bucher BT, Wheeler JC, Horns JJ, Paudel N, Hotaling JM. Healthcare Burden and Cost in Children with Anorectal Malformation During the First 5 Years of Life. J Pediatr 2022; 240:122-128.e2. [PMID: 34487770 DOI: 10.1016/j.jpeds.2021.08.083] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/27/2021] [Accepted: 08/30/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To identify cumulative 5-year healthcare costs and healthcare days in children with anorectal malformation (ARM) and to compare the cumulative 5-year healthcare costs and healthcare days in children with ARM with 3 control cohorts: healthy, premature, and congenital heart disease (CHD). STUDY DESIGN We performed a retrospective case-control study using the Truven MarketScan database of commercial claims encounters between 2008 and 2017. The ARM, CHD, and premature cohorts were identified using a targeted list of International Classification of Diseases 9th or 10th Revision diagnosis and Current Procedural Terminology codes. The healthy cohort included patients without ARM, preterm birth, or CHD. RESULTS We identified 664 children with ARM, 3356 children with heart disease, 63 190 children who were born preterm, and 2947 healthy patients. At 5 years, the total healthcare costs of children with ARM ($273K, 95% CI $168K-$378K) were similar to the premature cohort ($246K, 95% CI $237K-$255K) and lower than the CHD cohort ($466K, 95% CI $401K-$530K, P < .001). Total healthcare days were similar in children with ARM (158 days, 95% CI 117-198) and prematurity (141 days, 95% CI 137-144) but lower than CHD (223 days, 95% CI 197-250, P = .02). In ARM, outpatient care (126 days, 95% CI 93-159) represented the largest contribution to total healthcare days. CONCLUSIONS Children with ARM accumulate similar healthcare costs to children with prematurity and comparable healthcare days to children with CHD and prematurity in the first 5 years of life. Outpatient care represents the majority of healthcare days in children with ARM, identifying this as a target for quality improvement and demonstrating the long-term impact of this condition.
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Affiliation(s)
- Michael D Rollins
- Division of Pediatric Surgery, Department of Surgery, University of Utah Health, Salt Lake City, UT.
| | - Brian T Bucher
- Division of Pediatric Surgery, Department of Surgery, University of Utah Health, Salt Lake City, UT
| | - Justin C Wheeler
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of Utah Health, Salt Lake City, UT
| | - Joshua J Horns
- Department of Surgery, University of Utah Health, Salt Lake City, UT
| | - Niraj Paudel
- Department of Surgery, University of Utah Health, Salt Lake City, UT
| | - James M Hotaling
- Division of Urology, Department of Surgery, University of Utah Health, Salt Lake City, UT
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AbouZeid AA, Mohammad SA. Anatomical derangements after failed PSARP: correlating MRI and operative findings. ANNALS OF PEDIATRIC SURGERY 2021. [DOI: 10.1186/s43159-021-00094-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Redo surgery for anorectal anomalies (ARA) may be considered a special category of reconstructive surgery with less predictable outcomes. In this report, we studied anatomical derangements in a group of boys following a previously complicated PSARP procedure, in addition to the effect of reoperation on rectifying this distorted anatomy.
Results
The study included 27 boys who were re-operated after a previous complicated PSARP. Included cases were divided into two groups: group A (14 cases) was referred before colostomy closure with an obviously complicated primary operation, and group B (13 cases) was referred with delayed complications after colostomy closure.
Pelvic MRI examinations were performed before reoperation in 19 cases. In nine of these cases, a repeat MRI examination was performed at follow-up after reoperation to study the effect of redo surgery on rectifying the distorted anatomy.
Abnormal wide anorectal angle and wide pelvic hiatus were common anatomical derangements after a previously complicated PSARP. An important goal of reoperation was reconstruction of the levator ani behind the anorectum trying to create a more acute anorectal angle and a narrower pelvic hiatus. The success of this corrective step was evaluated by MRI comparing pre- and postoperative measurements that showed a favourable decrease in the values of anorectal angle and hiatal/PC ratio. Improvement of faecal continence was documented after reoperation in 8 out of 10 cases in group B.
Conclusion
A wide pelvic hiatus was a frequently encountered postsurgical complication after failed PSARP that has most probably resulted from poor reconstruction of the pelvic floor at time of the primary repair. Re-approximation of the split halves of levator ani in the midline behind the anorectum at reoperation can help to correct the distorted internal anatomy and improve bowel control in these cases.
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