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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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van der Steeg HJJ, van Rooij IALM, Iacobelli BD, Sloots CEJ, Morandi A, Broens PMA, Makedonsky I, Leon FF, Schmiedeke E, Vázquez AG, Miserez M, Lisi G, Midrio P, Amerstorfer EE, Fanjul M, Ludwiczek J, Stenström P, van der Steeg AFW, de Blaauw I. Bowel function and associated risk factors at preschool and early childhood age in children with anorectal malformation type rectovestibular fistula: An ARM-Net consortium study. J Pediatr Surg 2022; 57:89-96. [PMID: 35317943 DOI: 10.1016/j.jpedsurg.2022.02.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 01/31/2022] [Accepted: 02/08/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND Outcome of patients operated for anorectal malformation (ARM) type rectovestibular fistula (RVF) is generally considered to be good. However, large multi-center studies are scarce, mostly describing pooled outcome of different ARM-types, in adult patients. Therefore, counseling parents concerning the bowel function at early age is challenging. Aim of this study was to evaluate bowel function of RVF-patients at preschool/early childhood age and determine risk factors for poor functional outcome. METHODS A multi-center cohort study was performed. Patient characteristics, associated anomalies, sacral ratio, surgical procedures, post-reconstructive complications, one-year constipation, and Bowel Function Score (BFS) at 4-7 years of follow-up were registered. Groups with below normal (BFS < 17; subgroups 'poor' ≤ 11, and 'fair' 11 < BFS < 17) and good outcome (BFS ≥ 17) were formed. Univariable analyses were performed to detect risk factors for outcome. RESULTS The study included 111 RVF-patients. Median BFS was 16 (range 6-20). The 'below normal' group consisted of 61 patients (55.0%). Overall, we reported soiling, fecal accidents, and constipation in 64.9%, 35.1% and 70.3%, respectively. Bowel management was performed in 23.4% of patients. Risk factors for poor outcome were tethered cord and low sacral ratio, while sacral anomalies, low sacral ratio, prior enterostomy, post-reconstructive complications, and one-year constipation were for being on bowel management. CONCLUSIONS Although median BFS at 4-7 year follow-up is nearly normal, the majority of patients suffers from some degree of soiling and constipation, and almost 25% needs bowel management. Several factors were associated with poor bowel function outcome and bowel management. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Hendrik J J van der Steeg
- Department of Surgery-Pediatric Surgery, Amalia Children's Hospital, Radboud University Medical Center, Geert Grooteplein-Zuid 10, P.O. Box 9101, Nijmegen 6500 HB, the Netherland.
| | - Iris A L M van Rooij
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud UMC, Nijmegen, the Netherland
| | - Barbara D Iacobelli
- Department of Medical and Surgical Neonatology, Newborn Surgery Unit, Bambino Gesù Children's Hospital-Research Institute, Rome, Italy
| | - Cornelius E J Sloots
- Department of Pediatric Surgery, Erasmus Medical Center Sophia Children's Hospital, Rotterdam, the Netherland
| | - Anna Morandi
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paul M A Broens
- Department of Surgery, Division of Pediatric Surgery, University Medical Center Groningen, Groningen, the Netherland
| | - Igor Makedonsky
- Department of Pediatric Surgery, Children's Hospital Dnepropetrovsk, Dnepropetrovsk, Ukraine
| | | | - Eberhard Schmiedeke
- Department of Pediatric Surgery and Urology, Center for Child and Youth Health, Klinikum Bremen-Mitte, Bremen, Germany
| | | | - Marc Miserez
- Department of Abdominal Surgery, UZ Leuven, KU Leuven, Belgium
| | - Gabriele Lisi
- Department of Pediatric Surgery, University "Gabriele d'Annunzio " of Chieti-Pescara - "Santo Spirito" Hospital, Pescara, Italy
| | - Paola Midrio
- Department of Pediatric Surgery, Ca' Foncello Hospital, Treviso, Italy
| | - Eva E Amerstorfer
- Department of Pediatric and Adolescent Surgery, Medical University of Graz, Austria
| | - Maria Fanjul
- Department of Pediatric Surgery, Hospital Gregorio Marañón, Madrid, Spain
| | - Johanna Ludwiczek
- Department of Pediatric Surgery, Kepler Universitätsklinikum GmbH, Linz, Austria
| | - Pernilla Stenström
- Department of Pediatric Surgery, Skane University Hospital, Lund University, Lund, Sweden
| | - Alida F W van der Steeg
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, the Netherland; Department of Pediatric Surgery, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherland
| | - Ivo de Blaauw
- Department of Surgery-Pediatric Surgery, Amalia Children's Hospital, Radboud University Medical Center, Geert Grooteplein-Zuid 10, P.O. Box 9101, Nijmegen 6500 HB, the Netherland
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Perlman S, Shwartz I, Hazan Y, Weissbach A, Gilboa Y, Kravarusic D, Samuk I. Fetal Sacral Ratio: A Novel Method for Prenatal Sonographic Assessment of Sacral Abnormalities. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:2005-2010. [PMID: 34792823 DOI: 10.1002/jum.15882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 10/25/2021] [Accepted: 10/30/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES The sacral ratio (SR) was described as a postnatal X-ray-based method to detect sacral abnormalities and predict functional prognosis for fecal continence in children with anorectal malformations (ARMs). The present study aimed to describe a novel method of assessing sonographic fetal sacral ratio (f-SR) in a normal population of fetuses. METHODS Sixty three-dimensional (3D) ultrasound reconstruction images of the sacrum obtained from routine low-risk scans performed between 21 and 26 weeks of gestation served for measurement. The f-SR was calculated in a coronal view as the ratio between lines drawn at the upper and lower levels of the iliac bone and the 5th sacral vertebra. Bland-Altman plots assessed the inter- and intrareader variabilities of measurements. RESULTS The f-SR in the normal population of fetuses was 0.913 (±0.094). During the study period, three cases with ARM were examined and had a mean f-SR of 0.55. There was good repeatability of measurements and between readers' agreement. CONCLUSIONS The present study introduces a novel prenatal sonographic f-SR that can be reliably calculated on prenatal 3D ultrasound with good reliability and reproducibility. Future research will identify the clinical significance of f-SR abnormalities in ARM and their long-term impact on continence.
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Affiliation(s)
- Sharon Perlman
- Ultrasound Unit, The Helen Schneider Women's Hospital, Rabin Medical Center, Beilinson Campus, Petach Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Itai Shwartz
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yenon Hazan
- Ultrasound Unit, Department of Obstetrics and Gynecology, Kaplan Medical Center, Rehovot, Israel
- The Hebrew University and Hadassah Medical School, Jerusalem, Israel
| | - Avichai Weissbach
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Intensive Care Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Yinon Gilboa
- Ultrasound Unit, The Helen Schneider Women's Hospital, Rabin Medical Center, Beilinson Campus, Petach Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dragan Kravarusic
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Pediatric and Adolescent Surgery, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Inbal Samuk
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Colorectal Service, Department of Pediatric and Adolescent Surgery, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
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Correlation between the lateral and anteroposterior sacral ratios in anorectal malformations. Pediatr Radiol 2021; 51:1867-1872. [PMID: 33991195 DOI: 10.1007/s00247-021-05094-9] [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] [Received: 08/31/2020] [Revised: 03/10/2021] [Accepted: 04/28/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The sacral ratio has been used as a tool for evaluating sacral development in patients with anorectal malformations. Sacral ratios can be calculated by obtaining sacral radiographs in the anteroposterior (AP) and lateral planes. OBJECTIVE The objective of the study was to determine the correlation and agreement in sacral ratio calculations. MATERIALS AND METHODS In this single institution retrospective cohort study, we reviewed medical charts of all pediatric anorectal malformation patients treated between March 2014 and September 2018 who had both AP and lateral images of their sacrum. All sacral ratios were measured by three radiologists. Pearson's correlation coefficients and corresponding 95% confidence intervals (CIs) were used to assess the correlation between the AP and lateral radiographs. A weighted Kappa statistic was used to measure the agreement between how the AP and lateral sacral ratios categorized observations into risk groups. RESULTS Our initial cohort consisted of 646 observations from patients with anorectal malformations who had radiographs obtained in both AP and lateral planes. We excluded all observations (n=76) where the radiographs were deemed to be inadequate or not appropriately centered to measure sacral ratio. For a given pair of measurements, the mean lateral sacral ratio was 0.07 units greater than the AP plane (95% CI 0.06-0.09, paired t-test P-value <0.0001). AP and lateral images had a moderate positive correlation (Pearson's r=0.76, 95% CI 0.73-0.79, P<0.0001) and moderate agreement in risk categorization (unweighted kappa = 0.60, P<0.0001). AP and lateral readings conducted by all three radiologists had excellent inter-rater reliability with intraclass correlations for AP and lateral sacral ratios of 0.88 and 0.84, respectively. CONCLUSION Even though the AP and lateral sacral ratios had moderate positive correlation, the mean sacral ratio determined by images in the lateral plane was 0.07 units greater than the AP plane. AP and lateral sacral ratios concluded different risk categories relatively often. Future studies are needed to determine whether AP or lateral sacral ratios correlate better with continence in patients with anorectal malformations.
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