Revision Surgery in the Management of Anorectal Malformations: Experience from a Tertiary Center of India

Application of trinity new model home nursing in postoperative management of children with Hirschsprung's disease

OBJECTIVE

To explore the application effect of Trinity new model home nursing in postoperative management of children with Hirschsprung's disease (HD).

METHODS

A retrospective control research was designed, including 80 HD children underwent surgical treatment. According to the nursing model, the children were divided into control group (n=40) and observation group (n=40). They received conventional nursing and Trinity home nursing intervention respectively. The defecation function and quality of life, scores of self-rating anxiety scale (SAS) and family caregiver task inventory (FCTI), incidence of complications and nursing satisfaction before surgery, 3 and 6 months after surgery between the two groups were compared.

RESULTS

Compared with the control group, the children in the observation group had lower Wexner constipation and fecal incontinence scores at 3 and 6 months after surgery (both P<0.001), while the children's quality of life generic core scale (PedsQLTM4.0) scores at 6 months after operation were higher than those in the control group (P<0.001). The SAS and FCTI scores of family members in the observation group were lower than those in the control group after intervention (all P<0.001). Compared with the control group, the observation group had lower total incidence of complications and higher nursing satisfaction (all P<0.05).

CONCLUSION

Trinity new model home nursing can effectively increase the intestinal management quality of children undergoing HD surgery, improve their defecation function and quality of life, and reduce the risk of complications.

Constipation after surgery for anorectal malformations: Unrecognised problem until it is a problem

BACKGROUND

Constipation is a common problem after surgery for anorectal malformations (ARMs), especially in patients having preserved rectosigmoid after pull-down surgery. Here, we present our experience with patients having constipation after surgery for ARMs and briefly discuss its management.

MATERIALS AND METHODS

We retrospectively reviewed electronic operative and follow-up data from January 2015 to December 2019 of all patients having constipation after surgery for ARMs.

RESULTS

A total of 77 patients were included in the study. The median age was 60 months, and thirty patients were male. Primary diagnoses were rectourethral fistula (26; 33.77%), vestibular fistula (25; 32.47%), perineal fistula/ectopic anus (18; 23.38%), rectovaginal fistula (4; 5.19%) and imperforate anus without fistula (4; 5.19%). Anal stenosis was found in 20 (25.97%) patients, posterior ledge with an adequate anal opening in 5 (6.49%), displaced anus in 4 (5.19%) but no obvious problem found in 48 (62.34%) patients. Non-operative management was successful in 75.44% (43 out of 57) of patients. Surgery was performed in 32 out of 77 patients (41.56%) with no mortality. Forty-three (72.88%) patients are continent, stayed clean, but 16 (27.19%) patients still need some sort of laxative/bowel wash/enema intermittently (Grade I/II constipation). Incidence of constipation was higher in patients operated through anterior sagittal route (27.58%) than posterior sagittal route (23.94%), but it was not statistically significant (P = 0.479). Follow-up ranged from 3 months to 5 years.

CONCLUSION

Constipation is a common problem after ARMs surgery, especially in patients having preserved rectosigmoid after pull-down surgery. It is advisable to create relatively larger neoanus after pull through with early practice of neoanus dilatation, especially in redo cases. Repeated counselling, laxatives and dietary manipulations should begin at the first sign of constipation.

Assessing the previously repaired patient with an anorectal malformation who is not doing well

In this review, the care of children with a previously repaired anorectal malformation is explored. We know that the surgical care of children with anorectal malformations is complex; however, despite an increased understanding of the congenital anomaly and significant technical advances in the operative repair, many of these children continue to have poor functional outcomes. In this article we focus on the common surgical complications, discuss typical presentations, consider appropriate investigations, and review the risks and benefits of revisional surgery in those patients that are 'not doing well' following their primary reconstruction.

Treating pediatric colorectal patients in low and middle income settings: Creative adaptation to the resources available

Colorectal disease profiles for children in low- and middle-income settings (LMIC) are characterized by late presentation, increased complications and limited follow-up in many cases. There is a high prevalence of infectious conditions causing secondary colorectal disease such as Mycobacterium Tuberculosis(TB), Human Immunodeficiency Virus(HIV) and Human Papilloma Virus(HPV), which also impact the management of other primary colorectal conditions, such as wound-healing and intestinal anastomosis. Perineal trauma from sexual assault, motor vehicle or pedestrian accidents, burns, and traditional enemas are commonly encountered and may require adaptation of principles used in treatment of congenital anomalies such as Hirschsprung's disease and Anorectal Malformations for reconstruction. Endemic conditions in certain LMIC require further research to delineate underlying causes and optimize management, such as "African" degenerative visceral leiomyopathy, congenital pouch colon in the Indian subcontinent, and congenital H-type rectal fistulae prevalent in Asia. These unique disease profiles require creative adaptations of resources within poor healthcare infrastructure settings. These special challenges and pitfalls in colorectal care and complications of adverse socioeconomic conditions, are discussed.

General complications after surgery for anorectal malformations

The introduction of posterior sagittal anorectoplasty (PSARP) by deVries and Peña in the early 80s has impacted to the treatment of patients with anorectal malformations (ARM). It gained great recognition worldwide in a very short time, and since then, surgeons dealing with the treatment of this complex malformation could achieve tremendous progress in contemporary management of this anomaly. Despite the growing experience and body of information globally, the treatment of ARMs continues to be a challenge to the pediatric surgeons due to the nature and the variability of the anomaly, and short- and long-term problems continue to exist even after nearly 40 years of the PSARP era. Today, knowing more about it, pediatric surgeons are committed to do more for their ARM patients to have them as physically and socially healthy individuals.