Pediatric fecal incontinence: a surgeon's perspective

Quality of life outcomes in children after surgery for Hirschsprung disease and anorectal malformations: a systematic review and meta-analysis

Background

No systematic review and meta-analysis to date has examined multiple child and parent-reported social and physical quality of life (QoL) in pediatric populations affected by Hirschsprung’s disease (HD) and anorectal malformations (ARM). The objective of this systematic review is to quantitatively summarize the parent-reported and child-reported psychosocial and physical functioning scores of such children.

Methods

Records were sourced from the CENTRAL, EMBASE, and MEDLINE databases. Studies that reported child and parent reported QoL in children with HD and ARM, regardless of surgery intervention, versus children without HD and ARM, were included. The primary outcome was the psychosocial functioning scores, and the secondary outcomes were the presence of postoperative constipation, postoperative obstruction symptoms, fecal incontinence, and enterocolitis. A random effects meta-analysis was used.

Results

Twenty-three studies were included in the systematic review, with 11 studies included in the meta-analysis. Totally, 1678 total pediatric patients with HD and ARM underwent surgery vs 392 healthy controls. Pooled parent-reported standardized mean (SM) scores showed better social functioning after surgery (SM 91.79, 95% CI (80.3 to 103.3), I2=0). The pooled standardized mean difference (SMD) showed evidence for parent-reported incontinence but not for constipation in children with HD and ARM after surgery that had a lower mean QoL score compared with the normal population (SMD −1.24 (-1.79 to –0.69), I2=76% and SMD −0.45, 95% CI (−1.12 to 0.21), I2=75%). The pooled prevalence of child-reported constipation was 22% (95% CI (16% to 28%), I2=0%). The pooled prevalence of parent-reported postoperative obstruction symptoms was 61% (95% CI (41% to 81%), I2=41%).

Conclusion

The results demonstrate better social functioning after surgery, lower QoL scores for incontinence versus controls, and remaining constipation and postoperative obstruction symptoms after surgery in children with HD and ARM.

Healthcare Burden and Cost in Children with Anorectal Malformation During the First 5 Years of Life

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.

Comparison of longitudinal and radial characteristics of intra-anal pressures using 3D high-definition anorectal manometry between children with anoretal malformations and functional constipation

BACKGROUND

Pathophysiology of fecal incontinence (FI) in children with anorectal malformations (AM) is not well understood. Standard or high-resolution anorectal manometry (ARM) does not identify radial asymmetry or localize abnormal sphincter function. 3D high-definition anorectal manometry (HDARM) provides detailed topographic and 3D pressure gradient representation of anal canal.

AIMS

To compare intra-anal pressure profiles between children with AM and controls using HDARM and to determine the association between manometric properties and reported predictors of fecal continence (AM type, spinal anomaly, and sacral integrity).

METHODS

HDARM tracings of 30 children with AM and FI referred for ARM were compared with 30 age and sex-matched children with constipation. 2D pressure profiles were used to measure length of high-pressure zone (HPZ). Longitudinal and radial measurements of sphincter pressure at rest and squeeze were taken along each segment in 3D topographic views and compared between groups.

KEY RESULTS

3D measurements demonstrated longitudinal and radial differences between groups along all quadrants of HPZ. At rest, intra-anal pressures were lower along the four segments longitudinally across the anal canal and radially along the quadrants in AM group (P < .01). At squeeze, all quadrant pressures were lower in segments 1-4 in AM group (P < .01). Sensation was abnormal in AM group (P < .01). Intra-anal pressures longitudinally and radially were not associated with predictors of fecal continence.

CONCLUSIONS AND INFERENCES

Children with AM had abnormal sensation and lower pressures longitudinally and radially along all quadrants of anal canal. Manometric properties at rest were not associated with reported predictors of fecal continence.

Multi-institutional review of bowel management strategies in children with anorectal malformations

BACKGROUND/RATIONALE

To describe current bowel management program (BMP) strategies in anorectal malformation (ARM) patients based on patient-level predictors using data from a multi-institutional consortium.

MATERIALS/METHODS

Patient bowel function and BMP were reviewed from Pediatric Colorectal and Pelvic Learning Consortium (PCPLC) data. The PCPLC is comprised of multidisciplinary specialists researching colorectal and pelvic disorders. Seven US institutions submitted de-identified clinical data on ARM patients into a centralized patient registry.

RESULTS

The primary ARM of 624 patients was categorized into Mild (45.2%), Moderate (40.4%) or Complex (14.2%) anomaly classifications. Patient-specific BMP were examined based on age and on the presence of spinal cord/sacral anomalies. 418 (67%) enrolled patients were prescribed BMP (<5 yo 56.4%; ≥5-<12 yo 86.7%; ≥12 81.5%). Constipation was the primary chief complaint (80.2%). Forty percent of patients on a BMP were toilet trained and approximately one-half (48.5%) reported daytime stool accidents. Secondary surgical interventions for antegrade continence enemas (ACE) were examined; 14.5% of patients employed ACE strategies and utilization increased with age and varied based on anatomic anomalies.

CONCLUSIONS

This is the first report on BMP strategies for patients with ARM from the Pediatric Colorectal and Pelvic Learning Consortium. Individual patient characteristics are explored for their impact on bowel management strategy utilization.

LEVEL OF EVIDENCE

IV.

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.

Comparative analysis of occlusion methods for artificial sphincters

An artificial sphincter is a device that replaces the function of the biological sphincter by occluding the relative biological lumen. The investigation of occlusion methods for artificial sphincters is crucial for a reliable and effective design of such devices. The compression induced onto the tissue by a certain pressure depends on the biomechanical and physiological features of the lumen and on the specific occlusion method. A numerical model and an experimental evaluation are presented here to assess the efficiency of different occlusion methods. Numerical models of circumferential occlusion and clamping occlusion methods to simulate the compression of the biological lumen were developed. Results revealed a relationship between the efficiency of the occlusion method and the physiological condition of the lumen. With differences related to the testing setup, this relationship was also confirmed experimentally by conducting tests on biological simulators. We analyzed the occlusion method to adopt as the physiological pressure (ie, leakage pressure values) changed. In particular, we focused on the urinary incontinence, which is a dysfunction involving the external sphincter surrounding the urethra. In this scenario, we demonstrated that a clamping occlusion is an efficient method to compress the urethra, whose physiological pressures range between 4 and 12 kPa. The clamping occlusion method resulted up to 35% more efficient in terms of sealing pressure than the circumferential one for a closing pressure varying between 2.3 and 11.5 kPa.

Short versus mid-long-term outcome of transanal irrigation in children with spina bifida and anorectal malformations

PURPOSE

We assessed short- and mid-long-term clinical efficacy of transanal irrigation (TAI) and its effect on the quality of life of children with spina bifida (SB) and anorectal malformations (ARM).

METHODS

Seventy-four pediatric patients (age 6-17 years) with SB and ARM with neurogenic bowel dysfunction were enrolled for a prospective and multicentric study. Patients were evaluated before the beginning of TAI (T0), after 3 months (T1) and after at least 2 years (range 24-32 months) (T2) using a questionnaire assessing bowel function, the Bristol scale, and two validated questionnaires on quality of life: the CHQ-PF50 questionnaire for the parents of patients aged 6-11 years and the SF36 questionnaires for patients aged between 12 and 18 years.

RESULTS

Seventy-two patients completed TAI program in T1, and 67 continued into T2. Bowel outcomes (constipation and fecal incontinence) improved in both the SB and the ARM groups in the short and mid-long term. In both groups at T1 and T2, parents and children reported an improvement in quality of life and there was a significant increase of stool form types 4 and 5 as described by the Bristol scale. Common adverse effects during the study were similar at T1 and T2 without serious complications.

CONCLUSIONS

We observed a sustained improvement in bowel management and quality of life in SB and ARM children during the study, more significant in the short term than in mid-long term. To maintain success rates in the mid-long term and to reduce the dropout rate, we propose patient training and careful follow-ups.

Idiopathic constipation: A challenging but manageable problem

PURPOSE

A protocol to treat idiopathic constipation is presented.

METHODS

A contrast enema is performed in every patient and, when indicated, patients are initially submitted to a "clean out" protocol. All patients are started on a Senna-based laxative. The initial dosage is empirically determined and adjusted daily, during a one week period, based on history and abdominal radiographs, until the amount of Senna that empties the colon is reached. The management is considered successful when patients empty their colon daily and stop soiling. If the laxatives dose provokes abdominal cramping, distension, and vomiting, without producing bowel movements, patients are considered nonmanageable.

RESULTS

From 2005 to 2012, 215 patients were treated. 121 (56%) were males. The average age was 8.2years (range: 1-20). 160 patients (74%) presented encopresis. 67 patients (32%) needed a clean out. After one week, 181 patients (84%) achieved successful management, with an average Senna dose of 67mg (range: 5-175mg). In 34 patients (16%) the treatment was unsuccessful: 19 were nonmanageable, 3 noncompliant, and 12 continued soiling. At a later follow-up (median: 329days) the success rate for 174 patients was 81%.

CONCLUSION

We designed a successful protocol to manage idiopathic constipation. The key points are clean out before starting laxatives, individual adjustments of laxative, and radiological monitoring of colonic emptying.

TREATMENT STUDY

Level IV.

Anorectal Malformations

Anorectal malformation are common congenital problems occurring in 1 in 5,000 births and have a spectrum of anatomical presentations, requiring individualized treatments for the newborn, sophisticated approaches to the definitive reconstruction, and management of long-term treatments and outcomes. Associated anomalies related to the cardiac, renal, gynecologic, orthopedic, spinal, and sacral systems impact care and prognosis. Long-term results are good provided there is an accurate anatomical reconstruction and a focus on maximizing of functional results.

Surgical options for the management of severe functional constipation in children

PURPOSE OF REVIEW

Constipation is a very common problem in pediatrics with both the severity of presentations and treatments varying across a broad spectrum. The majority of children with functional constipation are managed successfully without the need for specialized testing and surgical intervention. Those who present with intractable constipation, with or without fecal soiling, require referrals for motility testing that helps determine both medical and surgical management, and interventions. The literature was reviewed for publications on surgical approaches to children with severe constipation, including assessing the quality and levels of evidence and the use of objective measures to determine outcomes.

RECENT FINDINGS

There is very little in the way of recent studies evaluating surgical indications or treatment approaches for functional constipation, apart from one systematic review and one recent expert review. Although the systematic review was published in the last year, most of the studies it analyzes are older. The vast majority of studies comprise level 4 and 5 evidence.

SUMMARY

The indication for most surgical procedures is 'failed' medical management, yet no standardized definition for this exists. Many surgical procedures are proposed with little evidence to show outcomes. We recommend that the surgical evaluation and treatment of children with constipation needs to be protocolized and studied in a prospective manner using validated outcomes measures. Our center's current protocol is described.

Effectiveness of an organized bowel management program in the management of severe chronic constipation in children

BACKGROUND

Chronic constipation is a common problem in children. The cause of constipation is often idiopathic, when no anatomic or physiologic etiology can be identified. In severe cases, low dose laxatives, stool softeners and small volume enemas are ineffective. The purpose of this study was to assess the effectiveness of a structured bowel management program in these children.

METHODS

We retrospectively reviewed children with chronic constipation without a history of anorectal malformation, Hirschsprung's disease or other anatomical lesions seen in our pediatric colorectal center. Our bowel management program consists of an intensive week where treatment is assessed and tailored based on clinical response and daily radiographs. Once a successful treatment plan is established, children are followed longitudinally. The number of patients requiring hospital admission during the year prior to and year after initiation of bowel management was compared using Fisher's exact test.

RESULTS

Forty-four children with refractory constipation have been followed in our colorectal center for greater than a year. Fifty percent had at least one hospitalization the year prior to treatment for obstructive symptoms. Children were treated with either high-dose laxatives starting at 2mg/kg of senna or enemas starting at 20ml/kg of normal saline. Treatment regimens were adjusted based on response to therapy. The admission rate one-year after enrollment was 9% including both adherent and nonadherent patients. This represents an 82% reduction in hospital admissions (p<0.001).

CONCLUSIONS

Implementation of a structured bowel management program similar to that used for children with anorectal malformations, is effective and reduces hospital admissions in children with severe chronic constipation.

The Hirschsprungs patient who is soiling after what was considered a "successful" pull-through

After surgery for Hirschsprungs disease, most children thrive, have few if any episodes of abdominal distention and enterocolitis, and are fecally continent. However, there exists a small group of patients who do not do well. Either they suffer from persistent distension and enterocolitis or they experience soiling after their pull-through procedure. These patients can be systematically evaluated and successfully treated with a combination of bowel management, dietary changes, and laxatives, and, in certain circumstances, a reoperation.

Long-term disease-specific quality of life in children and adolescent patients with ARM

BACKGROUND

The main aim of the present study was to investigate how fecal incontinence might influence different aspects of quality of life (QOL) in children and adolescents with anorectal malformations (ARMs). We considered both the influence of fecal incontinence at time 1 of the study and the influence of fecal incontinence at time 2 (4 years later) on QOL measured at time 2.

METHODS

A total of 175 parents from the Italian Parents' and Patients' Association for Anorectal Malformations completed a questionnaire about fecal incontinence in their children at time 1 of the study. Four years later, 97 of these parents completed the Hirschsprung Disease/Anorectal Malformation Quality of Life questionnaire. Patient ages ranged from 4 to 17 years. Quality of life areas from the Hirschsprung Disease/Anorectal Malformation Quality of Life questionnaire were considered as outcome variables in a hierarchical regression analyses where fecal incontinence at time 1 and at time 2 served as predictors.

RESULTS

The principal findings indicated that fecal incontinence at time 2 significantly predicted constipating diet, presence of diarrhea, urinary continence, social functioning, emotional functioning, body image, and physical symptoms, also when severity of the malformation was taken into account.

CONCLUSIONS

It is extremely important that pediatric surgeons continue to promote effective bowel management programs and that they work with other specialists and support associations to offer emotional and psychological support to patients with ARM and their families.