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Rajasegaran S, Ahmad NA, Tan SK, Lechmiannandan A, Mohamed OM, Cheng JQ, Hassan J, Sanmugam A, Singaravel S, Mohd Khalid H, Abdullah MY, Nah SA. Anorectal malformation and Hirschsprung's disease: a cross-sectional multicentre comparison of quality of life and bowel function to a healthy population. Arch Dis Child 2024:archdischild-2023-326724. [PMID: 38649254 DOI: 10.1136/archdischild-2023-326724] [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: 12/05/2023] [Accepted: 04/08/2024] [Indexed: 04/25/2024]
Abstract
PURPOSE Children with anorectal malformation (ARM) and Hirschsprung's disease (HD) often experience bowel symptoms into adulthood, despite definitive surgery. This study evaluates the quality of life (QOL) and bowel functional outcome of children treated for ARM and HD in comparison to healthy controls. METHODS Between December 2020 and February 2023, we recruited patients with ARM and HD aged 3-17 years at four tertiary referral centres, who had primary corrective surgery done >12 months prior. Healthy controls were age-matched and sex-matched. All participants completed the Pediatric Quality of Life Inventory Generic Core Scales 4.0, General Well-Being (GWB) Scale 3.0 and Family Impact (FI) Module 2.0 Questionnaires. Bowel Function Score (BFS) Questionnaires were also administered. We also performed subgroup analysis according to age categories. Appropriate statistical analysis was performed with p<0.05 significance. Ethical approval was obtained. RESULTS There were 306 participants: 101 ARM, 87 HD, 118 controls. Patients with ARM and HD had significantly worse Core and FI Scores compared with controls overall and in all age categories. In the GWB Scale, only ARM and HD adolescents (13-17 years) had worse scores than controls. ARM and HD had significantly worse BFSs compared with controls overall and in all age categories. There was significant positive correlation between BFS and Core Scores, GWB Scores and FI Scores. CONCLUSION Patients with ARM and HD had worse QOL than controls. Lower GWB Scores in adolescents suggests targeted interventions are necessary. Bowel function influences QOL, indicating the need for continuous support into adulthood.
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Affiliation(s)
- Suganthi Rajasegaran
- Department of Surgery, University of Malaya, Kuala Lumpur, Wilayah Persekutuan, Malaysia
| | - Nur Aini Ahmad
- Department of Paediatric Surgery, Sabah Women and Children's Hospital, Kota Kinabalu, Sabah, Malaysia
| | - Shung Ken Tan
- Paediatric Surgery Unit, Department of Surgery, Hospital Sultanah Bahiyah, Alor Setar, Kedah Darul Aman, Malaysia
| | - Abhirrami Lechmiannandan
- Department of Paediatric Surgery, Women's and Children's Hospital Kuala Lumpur, Hospital Tunku Azizah, Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur, Malaysia
| | - Omar Mazali Mohamed
- Department of Surgery, University Malaya Medical Center, Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Joo Qing Cheng
- Paediatric Surgery Unit, Department of Surgery, Hospital Sultanah Bahiyah, Alor Setar, Kedah Darul Aman, Malaysia
| | - Junaidah Hassan
- Paediatric Surgery Unit, Department of Surgery, Hospital Sultanah Bahiyah, Alor Setar, Kedah Darul Aman, Malaysia
| | - Anand Sanmugam
- Department of Surgery, University of Malaya, Kuala Lumpur, Wilayah Persekutuan, Malaysia
- Department of Surgery, University Malaya Medical Center, Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Srihari Singaravel
- Department of Surgery, University of Malaya, Kuala Lumpur, Wilayah Persekutuan, Malaysia
- Department of Surgery, University Malaya Medical Center, Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Hazlina Mohd Khalid
- Department of Paediatric Surgery, Sabah Women and Children's Hospital, Kota Kinabalu, Sabah, Malaysia
| | - Mohd Yusof Abdullah
- Department of Paediatric Surgery, Women's and Children's Hospital Kuala Lumpur, Hospital Tunku Azizah, Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur, Malaysia
| | - Shireen Anne Nah
- Department of Surgery, University of Malaya, Kuala Lumpur, Wilayah Persekutuan, Malaysia
- Department of Surgery, University Malaya Medical Center, Kuala Lumpur, Kuala Lumpur, Malaysia
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Beattie H, Subramanian T, Scudamore E, Middleton T, MacDonald C, Lindley R, Murthi G. Assessment of long-term quality of life, bowel and voiding function outcomes in patients with anorectal malformation at a single UK centre. Pediatr Surg Int 2024; 40:95. [PMID: 38565744 DOI: 10.1007/s00383-024-05684-2] [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] [Accepted: 03/22/2024] [Indexed: 04/04/2024]
Abstract
AIMS Assess long-term quality of life (QoL), bowel and voiding function in anorectal malformation (ARM) paediatric patients. METHOD Retrospective review of ARM patients between 2007 and 2020 was performed. QoL (all patients), bowel and voiding function (> 5 yo) were assessed using the paediatric quality of life inventory (PedsQL), paediatric incontinence and constipation score (PICS) and dysfunctional voiding scoring system (DVSS), respectively. RESULTS There were 122 patients (49% female, 85 > 5 yo) with ARM. Two had died, four refused, twenty-two were non-contactable, leaving ninety-four patients (65 > 5 yo) included. Mean age was 89 months (19-183), and follow-up was 86 months (13-183). Patients had significantly poorer scores for QoL, bowel and voiding function compared to published healthy controls. 57% had poor bowel function, 32% had poor voiding function and 38% required 'ancillary aids' to facilitate function. Patients using 'ancillary aids' for voiding function had a significantly lower QoL (parent: 62 vs 77; p = 0.01, patient: 66 vs 79; p = 0.05). Bowel continence was worse in those with high vs low ARM (13 vs 20, p = 0.004) and timely vs delayed diagnosis (17 vs 24, p = 0.04). CONCLUSION Patients with ARM have significantly worse QoL, bowel and voiding function than normal healthy controls. There is a need for long-term monitoring of function and further support for these children. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Harriet Beattie
- Paediatric Surgical Unit, Sheffield Children's NHS Foundation Trust, Sheffield, S10 2TH, UK
- The Medical School, University of Sheffield, Sheffield, S10 2RX, UK
| | - Thejasvi Subramanian
- Paediatric Surgical Unit, Sheffield Children's NHS Foundation Trust, Sheffield, S10 2TH, UK
| | - Elizabeth Scudamore
- Paediatric Surgical Unit, Sheffield Children's NHS Foundation Trust, Sheffield, S10 2TH, UK
| | - Thomas Middleton
- Paediatric Surgical Unit, Sheffield Children's NHS Foundation Trust, Sheffield, S10 2TH, UK
| | - Caroline MacDonald
- Paediatric Surgical Unit, Sheffield Children's NHS Foundation Trust, Sheffield, S10 2TH, UK
| | - Richard Lindley
- Paediatric Surgical Unit, Sheffield Children's NHS Foundation Trust, Sheffield, S10 2TH, UK
| | - Govind Murthi
- Paediatric Surgical Unit, Sheffield Children's NHS Foundation Trust, Sheffield, S10 2TH, UK.
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Gertler J, Löf Granström A, Oddsberg J, Gunnarsdóttir A, Svenningsson A, Wester T, Örtqvist L. Functional and Health-Related Quality of Life Outcomes into Adulthood for Females Surgically Treated for Anorectal Malformation. J Pediatr Surg 2024:S0022-3468(24)00093-9. [PMID: 38443293 DOI: 10.1016/j.jpedsurg.2024.02.011] [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: 11/14/2023] [Revised: 01/21/2024] [Accepted: 02/14/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND Controlled outcomes into adulthood for females with anorectal malformation (ARM) are still scantily studied. The primary aim was to investigate bowel function, bladder function and health-related quality of life (HRQoL) in females operated for ARM. METHODS A cross-sectional questionnaire-based observational study was performed including females treated for ARM at our institution between 1994 and 2017. The bowel function was assessed with bowel function score (BFS) and urinary tract function with lower urinary tract symptoms (LUTS) questionnaires. HRQoL was investigated with validated age-dependent questionnaires. Patient characteristics were retrospectively retrieved from the medical records and descriptive statistics were used for analysis. HRQoL outcomes were compared with normative data whilst bowel and bladder function outcomes were compared to age-matched female controls. RESULTS Forty-four (41.5 %) of 106 females responded to the questionnaires. Ten of 29 patients (34.5 %) aged 4-17 years and 4 of 14 patients (28.6%) aged ≥18 years, reported a well-preserved bowel function (BFS≥17). Constipation issues decreased with age. BFS was similar in patients with perineal and vestibular fistulas. Thirty-six (83.7%) of the patients had at least one LUTS. No adult patients had issues with involuntary urinary leakage. Adults scored significantly (p = 0.004) lower than normative data regarding HRQoL, while children and adolescents scored comparably to norm data. CONCLUSIONS Only 28.6 % of the adult patients reported a well-preserved bowel function, similar to the proportion reported by children 4-17 years of age. Adult patients appear to have a diminished HRQoL, however the correlation with BFS was weak. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Joshua Gertler
- Unit of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden; Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.
| | - Anna Löf Granström
- Unit of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden; Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Jenny Oddsberg
- Unit of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden; Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Anna Gunnarsdóttir
- Unit of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden; Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Anna Svenningsson
- Unit of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden; Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Tomas Wester
- Unit of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden; Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Lisa Örtqvist
- Unit of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden; Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
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Røkkum H, Johannessen H, Bjørnland K. Perioperative and Long-Term Outcome in Patients Treated for Jejunoileal Atresia. J Pediatr Gastroenterol Nutr 2023; 76:434-439. [PMID: 36727903 DOI: 10.1097/mpg.0000000000003709] [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] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Jejunoileal atresia is a common cause of neonatal intestinal obstruction. Results of long-term outcome are very limited. The aim of this study was to describe perioperative and postoperative outcome, and to evaluate long-term gastrointestinal quality of life (QoL) in patients treated for jejunoileal atresia. METHODS We conducted a combined retrospective and cross-sectional observational study of patients treated for jejunoileal atresia during 2001-2019. Perioperative data were registered, and complications were classified according to the Clavien-Dindo classification. To evaluate long-term clinical status and QoL, the PedsQL Gastrointestinal Symptoms Scales questionnaire and a self-designed questionnaire were used. Approval from the Data Protection Office was obtained. RESULTS Seventy patients were included in the retrospective part of the study. Of these, 70% got a primary anastomosis. Concomitant anomalies were registered in 46%. Median length of stay was 28 (5-140) days. Early (<28 days) complication rate was 66%. Early abdominal surgical reinterventions were performed in 11%, most frequently due to anastomotic leak. Late (>28 days) abdominal surgical reinterventions were performed in 21%, and most commonly for bowel obstruction. Overall mortality rate was 4%. Thirty-two patients with median 8 (2-19) years returned the questionnaires. Overall gastrointestinal QoL was good. However, concomitant gastrointestinal anomalies were associated with impaired outcome. Embarrassment of the scar was reported in 38%. Three (9%) patients used medication (laxatives, proton pump inhibitor) for gastrointestinal symptoms. CONCLUSIONS Jejunoileal atresia is associated with significant morbidity during initial treatment. Despite this, the majority of the patients have excellent long-term outcomes.
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Affiliation(s)
- Henrik Røkkum
- From the Department of Pediatric Surgery, Oslo University Hospital, Oslo, Norway
- University of Oslo, Oslo, Norway
| | | | - Kristin Bjørnland
- From the Department of Pediatric Surgery, Oslo University Hospital, Oslo, Norway
- University of Oslo, Oslo, Norway
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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: 2] [Impact Index Per Article: 1.0] [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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Patient-reported outcome measures in pediatric surgery - A systematic review. J Pediatr Surg 2022; 57:798-812. [PMID: 35123787 DOI: 10.1016/j.jpedsurg.2021.12.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 12/29/2021] [Indexed: 11/21/2022]
Abstract
PURPOSE With improved long-term survival rates, measuring the quality of surgical care has gradually shifted from clinical morbidity and mortality to patient-reported outcome measures (PROMs). Since the use of PROMs in pediatric surgery is still limited, we undertook a study to identify current PROMs, assess their characteristics, and identify gaps and areas for improvement. METHODS A search was conducted in eight databases from their inception until May 2021 to identify PROMs that have been used in pediatric surgical patients. PRISMA standards were followed, and screening was completed by two independent reviewers. The quality of the included studies was appraised using the AXIS and the Mixed Methods Appraisal Tool. RESULTS Of 8282 studies screened, 101 articles met the inclusion criteria. Most of the studies (99%) were cross-sectional. We identified 85 different PROMs among the studies, 53 being disease-specific and the rest generic. The PedsQL™ was the most frequently used tool (42 studies). Almost half of the instruments (41 studies) were not validated, and 28% were developed ad hoc for each specific study. Significantly, all PROMs encountered were standardized (consisting of pre-determined domains), with no individualized tools currently in use. The overall quality of the included studies was good. CONCLUSIONS PROMs are increasingly used in pediatric surgery. Disease-specific PROMs predominate the field, yet validated and especially individualized PROMs are notably absent. Future efforts are needed to develop robust tools that reflect individual patient and family needs, preferences, and values, with the aim of furthering family-centered pediatric surgical care.
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Svetanoff WJ, Kapalu CL, Lopez JJ, Fraser JA, Briggs KB, Rentea RM. Psychosocial factors affecting quality of life in patients with anorectal malformation and Hirschsprung disease-a qualitative systematic review. J Pediatr Surg 2022; 57:387-393. [PMID: 34127258 DOI: 10.1016/j.jpedsurg.2021.05.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 04/07/2021] [Accepted: 05/02/2021] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Little is known about psychosocial and behavioral factors that impact the quality of life of patient's with anorectal malformations (ARM) and Hirschsprung disease (HSCR). We aimed to highlight the psychosocial, emotional, and behavioral themes that affect these patients. METHODS A qualitative literature review of articles published between 1980 and 2019 was performed. Articles that reported quality of life (QoL) measures not directly related to bowel function and incorporated data on patients aged 0-21 years old were included. Data were separated based on distinct developmental time points. RESULTS In the neonatal period, parents relayed uncertainty about the future and feeling overwhelmed by lack of social support. Difficulties with anxiety, peer rejection, and behavioral problems were noted in primary grades, while adolescents experienced low self-confidence, poor body image, and depression. Young adults expressed hesitancy to engage in romantic relationships or sexual activity. Lack of long-term follow-up, an incomplete transition to adult healthcare, and lack of psychology services leave young adults without guidance to manage a chronic condition. CONCLUSION Multiple psychosocial stressors are present in the lives of ARM and HSCR patients. Provision of developmentally matched medical, psychological, and community-based supports for ARM and HSCR patients and their families can lead to improved QoL.
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Affiliation(s)
- Wendy Jo Svetanoff
- Comprehensive Colorectal Center, Children's Mercy-Kansas City, Kansas City, MO, United States; Department of Surgery, Children's Mercy Hospital Kansas City, MO, United States
| | - Christina Low Kapalu
- Comprehensive Colorectal Center, Children's Mercy-Kansas City, Kansas City, MO, United States; Department of Gastroenterology, Hepatology, and Nutrition, Children's Mercy Hospital Kansas City, MO, United States; University of Missouri-Kansas City School of Medicine, United States
| | - Joseph J Lopez
- Comprehensive Colorectal Center, Children's Mercy-Kansas City, Kansas City, MO, United States; Department of Surgery, Children's Mercy Hospital Kansas City, MO, United States
| | - James A Fraser
- Comprehensive Colorectal Center, Children's Mercy-Kansas City, Kansas City, MO, United States; Department of Surgery, Children's Mercy Hospital Kansas City, MO, United States
| | - Kayla B Briggs
- Comprehensive Colorectal Center, Children's Mercy-Kansas City, Kansas City, MO, United States; Department of Surgery, Children's Mercy Hospital Kansas City, MO, United States
| | - Rebecca M Rentea
- Comprehensive Colorectal Center, Children's Mercy-Kansas City, Kansas City, MO, United States; Department of Surgery, Children's Mercy Hospital Kansas City, MO, United States; University of Missouri-Kansas City School of Medicine, United States.
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Huang X, Tan SS, Chen Y, Li T. Acquired Rectourethral and Rectovaginal Fistulas in Children: A Systematic Review. Front Pediatr 2021; 9:657251. [PMID: 34026691 PMCID: PMC8138555 DOI: 10.3389/fped.2021.657251] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 04/12/2021] [Indexed: 01/22/2023] Open
Abstract
Background: Acquired rectourethral (RUF) or rectovaginal fistulas (RVF) in children are rare conditions in pediatric surgery. Prior literature are retrospective studies and based on a small number of patients. The managements and outcomes vary widely across different studies. No standard or recommended management has been universally adopted. The goal was to systematically summarize different causes, provide an overlook of current clinical trend and to derive recommendation from the literature regarding the etiology, managements, and outcomes of pediatric acquired RUF and RVF. Methods: PubMed, Embase, Cochrane databases were searched using terms: rectourethral fistula, recto-urethral fistula, urethrorectal fistula, urethro-rectal fistula, rectovaginal fistula. All studies were retrospective, in English, and included patients under the age of 18 years. Any series with congenital cases, adult (>18 years), <2 fistula cases less and obstetric related causes were excluded. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guideline was followed. Results: Of the 531 records identified, 26 articles with 163 patients (63 RUF and 100RVF) were fully analyzed. Most RUF resulted from trauma, most RVF were from infection of HIV. About 92 patients underwent 1 of 3 categories of definitive repair, including transanal (4.3%), trans-sphincteric (48.9%), and transperineal (30.4%). Tissue interposition flaps were used in 37.6% patients, while temporary fecal diversions were used in 63.9% patients. Fistula was successfully closed in 50.3% patients (98.4% RUF and 20% RVF). 89.1 and 79.7 % of surgical repair patients had optimal fecal and urinary functions, respectively. In the inflammatory bowel disease and HIV infection related RVF patient group, the closure rate was prohibitive poor. Conclusions: Most RVF are a sign of systematic diseases like HIV-infection or IBD and are associated with poor general conditions. While conservative treatment is recommended, stable patients can benefit from surgery. Further investigation is recommended if RVF are encountered without trauma or surgical history. RUF are likely to result from trauma or surgery, and transperineal or trans-sphincter approach can lead to closure and optimal function results. Fecal diversion and/or urinary diversion are helpful in some cases, while interposition technique may not be necessary. An objective scoring system for long-term follow-up and reporting consensus is needed to address treatment inconsistence.
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Affiliation(s)
- Xinjie Huang
- Department of General Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Sarah Siyin Tan
- Department of General Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Yajun Chen
- Department of General Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Tian Li
- Department of Biomedical Engineering, The Fourth Military Medical University, Xi'an, China
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Functional outcome, quality of life, and 'failures' following pull-through surgery for hirschsprung's disease: A review of practice at a single-center. J Pediatr Surg 2020; 55:273-277. [PMID: 31759654 DOI: 10.1016/j.jpedsurg.2019.10.042] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 10/26/2019] [Indexed: 12/13/2022]
Abstract
AIMS The purpose of this study was to assess bowel function and quality of life (QoL) in patients with Hirschsprung's disease (HD) and identify patients who have 'failed' treatment. METHODS A review of a single-center HD cohort treated with pull-through surgery from 2004 to 2017 was completed. Bowel function of patients five years and above and QoL of all patients were assessed using validated questionnaires. Patients who 'failed' treatment were defined as above five years with one or more of: a) long-term stoma, b) needing an antegrade continence enema or transanal irrigation, c) severe soiling, or d) severe constipation. Statistical analysis was performed with P < 0.05 deemed significant. Data are given as mean [range]. RESULTS Seventy-one patients presented with HD within the study period. Mean follow-up was 5.4 years [0.7-13.3]. Of 38 eligible patients, bowel function was assessed in 24 patients (nine had a stoma, five lost to follow-up). The mean incontinence score was 17 [0-28)], and the mean constipation score was 17 [5-25]. Incontinence and constipation scores were worse than healthy controls (P < 0.001 and P = 0.001, respectively) and did not improve with age. Fifty-six patients had QoL assessed with no difference between our cohort (81 [25-100]) and healthy controls (81 [unknown]); (P = 0.85). Thirty-three patients were assessed for 'failure' (bowel function score n = 24; stoma n = 9). Thirty of 33 (91%) children older than five years can be considered to have 'failed' treatment. CONCLUSIONS Patients have worse bowel function than healthy children, which does not improve with age. QoL is comparable to healthy controls. A significant proportion of patients have poor outcomes and have 'failed' treatment. LEVEL OF EVIDENCE Level III.
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Children and adolescents with VACTERL association: health-related quality of life and psychological well-being in children and adolescents and their parents. Qual Life Res 2019; 29:913-924. [PMID: 31741214 PMCID: PMC7142056 DOI: 10.1007/s11136-019-02364-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2019] [Indexed: 12/15/2022]
Abstract
Purpose VACTERL association is a rare and complex condition of congenital malformations, often requiring repeated surgery and entailing various physical sequelae. Due to scarcity of knowledge, the study aim was to investigate self-reported health-related quality of life (HRQoL), anxiety, depression and self-concept in children and adolescents with VACTERL association and self-reported anxiety and depression in their parents. Methods Patients aged 8–17 years with VACTERL association and their parents were recruited from three of four Swedish paediatric surgical centres during 2015–2019. The well-established validated questionnaires DISABKIDS, Beck Youth Inventories, Beck Anxiety Inventory and Beck Depression Inventory were sent to the families. Data were analysed using descriptives, t tests and multivariable analysis. Results were compared with norm groups and reference samples. Results The questionnaires were returned by 40 patients, 38 mothers and 33 fathers. The mean HRQoL was M = 80.4, comparable to children with asthma (M = 80.2) and diabetes (M = 79.5). Self-reported psychological well-being was comparable to the norm group of Swedish school children, and was significantly higher than a clinical sample. Factors negatively influencing children’s HRQoL and psychological well-being were identified. The parents’ self-reports of anxiety and depression were comparable to non-clinical samples. Conclusions Although children and adolescents with VACTERL association reported similar HRQoL to those of European children with chronic conditions, their psychological well-being was comparable to Swedish school children in general. Nevertheless, some individuals among both children and parents were in need of extra support. This attained knowledge is valuable when counselling parents regarding the prognosis for children with VACTERL association.
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Wigander H, Nisell M, Frenckner B, Wester T, Brodin U, Öjmyr-Joelsson M. Quality of life and functional outcome in Swedish children with low anorectal malformations: a follow-up study. Pediatr Surg Int 2019; 35:583-590. [PMID: 30729983 PMCID: PMC6456466 DOI: 10.1007/s00383-018-04431-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/14/2018] [Indexed: 12/29/2022]
Abstract
PURPOSE The aim was to investigate the quality of life and bowel function in children with low anorectal malformations (ARM). ADDITIONAL AIM To evaluate the Swedish version the Hirschsprung's Disease/Anorectal Malformation Quality of life Questionnaire (HAQL). METHODS Forty-four children and their parents were invited to complete the HAQL and the Bowel Function Score (BFS). Healthy children participated as controls and completed the HAQL. RESULTS Seventeen children and 18 mothers completed the HAQL. The children reported impaired function in the physical symptom (PH) fecal continence (FC) and laxative diet (LD) domains compared to controls. Compared with their mothers, they reported impaired physical function and more symptoms in the emotional functioning (EMF) and PH domains. 27 families completed the BFS; 63% reported normal bowel function, 33% moderate outcome and one patient, comprising 4%, poor outcome. Evaluation of the HAQL, FC, EMF and PH domains showed no obvious conflicts. CONCLUSIONS The children did not differ much regarding their QoL, even though they appeared to have impaired bowel function and worse emotional functioning compared to controls. The mothers underestimated their children's physical symptoms and overestimated their emotional functioning. Evaluated domains in the HAQL appear to work as intended, but the questionnaire needs further development.
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Affiliation(s)
- Helena Wigander
- Department of Women's and Children's Health, Karolinska Institutet, 171 76, Stockholm, Sweden.
- Division of Pediatric Surgery, Astrid Lindgren Children's Hospital, Karolinska University Hospital, 171 76, Stockholm, Sweden.
| | - Margret Nisell
- Department of Health Sciences, The Swedish Red Cross University College, Huddinge, Sweden
- Division of Child- and Adolescent Psychiatry, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Björn Frenckner
- Department of Women's and Children's Health, Karolinska Institutet, 171 76, Stockholm, Sweden
- Division of Pediatric Surgery, Astrid Lindgren Children's Hospital, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - Tomas Wester
- Department of Women's and Children's Health, Karolinska Institutet, 171 76, Stockholm, Sweden
- Division of Pediatric Surgery, Astrid Lindgren Children's Hospital, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - Ulf Brodin
- The Medical Statistic Unit, Department for Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Maria Öjmyr-Joelsson
- Department of Women's and Children's Health, Karolinska Institutet, 171 76, Stockholm, Sweden
- Division of Pediatric Surgery, Astrid Lindgren Children's Hospital, Karolinska University Hospital, 171 76, Stockholm, Sweden
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Kaška M, Chobola M, Skalská H, Maňák J, Sobotka L. Quality of Life after Reconstructive Surgery for Intestinal Fistulas. ACTA MEDICA (HRADEC KRÁLOVÉ) 2018; 61:103-107. [PMID: 30543515 DOI: 10.14712/18059694.2018.126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND This retrospective clinical study would like to objectively denote a quality of life of persons afflicted by an abdominal catastrophe and managed by an extensive surgery can be almost as well conformable as those of healthy people in a similar age group. METHODS A set of eighteen patients who were successfully surgically treated and cured enjoyed a relatively good convalescence after their surgery and returned to a satisfactory standard of life from the point of view of organ function and psychosomatic state. Statistical analysis of the data collected over a period of 1 to 6 years after this complex therapy using special questionnaire for QOL assessment SF-36 was performed. RESULTS Almost half of the patients evaluated their state similarly to the rest of the population of comparable age and general health status. The remainder of the patients declared significantly worse evaluations in the majority of the observed domains of the questionnaire. CONCLUSION Therapy of these patients was and must be complex: it included preparation for surgery at a special metabolic internal site, careful diagnostics of the digestive tract state, suitable surgery and good quality care after the surgery.
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Affiliation(s)
- Milan Kaška
- Department of Surgery, Teaching Hospital, Hradec Králové and Academic Department of Surgery, Charles University, Faculty of Medicine in Hradec Králové, Hradec Králové, Czech Republic.
| | - Milan Chobola
- Department of Informatics and Quantitative Methods, University of Hradec Králové, Czech Republic
| | - Hana Skalská
- Department of Informatics and Quantitative Methods, University of Hradec Králové, Czech Republic
| | - Jan Maňák
- Department of Gerontology and Metabolism, Teaching Hospital Hradec Králové, Charles University, Faculty of Medicine in Hradec Králové, Hradec Králové, Czech Republic
| | - Luboš Sobotka
- Department of Gerontology and Metabolism, Teaching Hospital Hradec Králové, Charles University, Faculty of Medicine in Hradec Králové, Hradec Králové, Czech Republic
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Nah SA, Ong CCP, Saffari SE, Ong LY, Yap TL, Low Y, Jacobsen AS. Anorectal malformation & Hirschsprung's disease: A cross-sectional comparison of quality of life and bowel function to healthy controls. J Pediatr Surg 2018; 53:1550-1554. [PMID: 28916047 DOI: 10.1016/j.jpedsurg.2017.08.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 08/14/2017] [Accepted: 08/21/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND Patients with anorectal malformation (ARM) and Hirschsprung's disease (HD) face long-term disturbance in bowel function even after definitive surgery. This study evaluates the quality of life (QOL) of patients with ARM and HD, and compares them to healthy controls using self-report questionnaires. METHODOLOGY A prospective study was performed recruiting patients with ARM or HD from September 2013 to December 2014 who had primary surgery done in our institution at least 2 years prior to participation. Age-matched and gender-matched controls were enrolled from our patients with minor outpatient complaints. All participants completed the following PedsQL™ scales (maximum score 100): 4.0 Generic Core Scales, 3.0 General Well-Being (GWB) Scale and 2.0 Family Impact (FI) Module. All were also scored on bowel function (BFS), with a maximum score 20. Appropriate statistical analysis was performed, with significance level <0.05. RESULTS There were 193 participants: 87 controls, 62 ARM, 44 HD. When comparing Core, GWB and FI scores, there were no significant differences between groups although controls had best scores indicating best QOL and general wellbeing, with least impact of the child's health on the family. BFS was significantly different with controls having best and ARM worst scores. There were no significant differences in scores between parent and child indicating intradyad consistency. There was significant positive correlation between BFS and Core (p<0.0001), and between BFS and GWB scores (p<0.005); and significant negative correlation between BFS and FI scores (p<0.0001). CONCLUSIONS Bowel function impacts quality of life. Those with ARM and HD can achieve good quality of life comparable to controls, based on patient and caregiver self-reported outcomes. TYPE OF STUDY Prospective comparative study LEVEL OF EVIDENCE: Level II.
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Affiliation(s)
- Shireen Anne Nah
- Department of Paediatric Surgery, KK Women's & Children's Hospital, Singapore
| | - Caroline C P Ong
- Department of Paediatric Surgery, KK Women's & Children's Hospital, Singapore
| | | | - Lin Yin Ong
- Department of Paediatric Surgery, KK Women's & Children's Hospital, Singapore
| | - Te-Lu Yap
- Department of Paediatric Surgery, KK Women's & Children's Hospital, Singapore
| | - Yee Low
- Department of Paediatric Surgery, KK Women's & Children's Hospital, Singapore
| | - Anette S Jacobsen
- Department of Paediatric Surgery, KK Women's & Children's Hospital, Singapore.
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Cairo SB, Chiu PPL, Dasgupta R, Diefenbach KA, Goldstein AM, Hamilton NA, Lo A, Rollins MD, Rothstein DH. Transitions in care from pediatric to adult general surgery: Evaluating an unmet need for patients with anorectal malformation and Hirschsprung disease. J Pediatr Surg 2018; 53:1566-1572. [PMID: 29079318 DOI: 10.1016/j.jpedsurg.2017.09.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 08/10/2017] [Accepted: 09/02/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND The provision of timely and comprehensive transition of care from pediatric to adult surgical providers for patients who have undergone childhood operations remains a challenge. Understanding the barriers to transition from a patient and family perspective may improve this process. METHODS A cross-sectional survey was conducted of patients with a history of anorectal malformation (ARM) or Hirschsprung Disease (HD) and their families. The web-based survey was administered through two support groups dedicated to the needs of individuals born with these congenital abnormalities. Categorical variables were compared using Chi-squared and Fisher's exact test with Student's t test and ANOVA for continuous variables. RESULTS A total of 118 surveys were completed (approximately 26.2% response). The average age of patients at time of survey was 12.3years (SD 11.6) with 64.5% less than 15years old. The primary diagnosis was reported for 78.8% patients and included HD (29.0%), ARM (61.3%), and cloaca (9.7%). The average distance traveled for ongoing care was 186.6miles (SD 278.3) with 40.9% of patients traveling ≥30miles; the distance was statistically significantly greater for patients with ARM (p<0.001). With regards to ongoing symptoms, 44.1% experience constipation, 40.9% experience diarrhea, and approximately 40.9% require chronic medication for management of bowel symptoms; only 3 respondents (3.2%) reported fecal incontinence. The majority of patients, 52.7% reported being seen by a provider at least twice per year and the majority continued to be followed by a pediatric provider, consistent with the majority of the cohort being less than 18years of age. Conversations with providers regarding transitioning to an adult physician had occurred in fewer than 13% of patients. The most commonly cited barrier to transition was the perception that adult providers would be ill-equipped to manage the persistent bowel symptoms. CONCLUSION Patients undergoing childhood procedures for ARM or HD have a high prevalence of ongoing symptoms related to bowel function but very few have had conversations regarding transitions in care. Early implementation of transitional care plans and engagement of adult providers are imperative to transitions and may confer long-term health benefits in this patient population. LEVEL OF EVIDENCE Level IV, case series with no comparison group.
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Affiliation(s)
- Sarah B Cairo
- Women and Children's Hospital of Buffalo, 140 Hodge Street, Buffalo, NY 14222.
| | - Priscilla P L Chiu
- The Hospital for SickKids, 555 University Avenue, Toronto, Canada M5G 1X8.
| | - Roshni Dasgupta
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 35229.
| | - Karen A Diefenbach
- Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205.
| | - Allan M Goldstein
- Massachusetts General Hospital, Harvard Medical School, 55 Fruit St., Boston, MA 02114.
| | - Nicholas A Hamilton
- Oregon Health Sciences University, Doernbecher Children's Hospital, 700 SW Campus Dr, Portland, OR 97239.
| | - Andrea Lo
- The University of Chicago Medicine Comer Children's, 5721 S Maryland Ave, Chicago, IL 60637.
| | - Michael D Rollins
- University of Utah School of Medicine, Primary Children's Hospital, 100 N Mario Capecchi Drive, Salt Lake City, UT 84113.
| | - David H Rothstein
- Women and Children's Hospital of Buffalo, 140 Hodge Street, Buffalo, NY 14222; State University of New York at Buffalo, Department of Surgery, 3435 Main Street, Buffalo, NY 14214.
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Grano C, Fernandes M, Bucci S, Aminoff D, Lucidi F, Violani C. Self-efficacy beliefs, faecal incontinence and health-related quality of life in patients born with anorectal malformations. Colorectal Dis 2018; 20:711-718. [PMID: 29751372 DOI: 10.1111/codi.14259] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 12/30/2017] [Indexed: 12/13/2022]
Abstract
AIM Anorectal malformations (ARMs) are rare congenital colorectal anomalies with long lasting consequences, among which faecal incontinence is one of the most relevant since it may strongly affect patients' health-related quality of life (HRQoL). Although a growing body of literature supports the importance of self-efficacy in chronic disease health outcomes, only few studies have focused on self-efficacy in ARMs and in faecal incontinence. The purpose of the present study is to examine the mediational role of self-efficacy in the path between faecal incontinence and HRQoL in patients born with ARMs. METHOD Ninety-eight adult patients from the Italian Association for Anorectal Malformations (AIMAR) responded to measures of faecal incontinence, self-efficacy for managing ARM consequences, and physical and mental HRQoL (SF-36). Data were analysed by means of structural equation models. RESULTS The tested model provides support for the guiding hypothesis. Fit indices indicate that the model fits the data well (χ2 = 33.48, df = 23, P = 0.07; comparative fit index [CFI] = 0.97; root mean square error of approximation [RMSEA] = 0.07; standardized root mean square residual [SRMR] = 0.05). Faecal incontinence has negative effects on both physical and mental HRQoL, as well on self-efficacy. In turn, self-efficacy has a positive and direct effect on mental HRQoL. CONCLUSION Faecal incontinence is the most relevant and negative factor influencing HRQoL; in addition, self-efficacy contributes in reducing emotional distress and in improving mental health outcomes. Longitudinal and controlled studies may be helpful to evaluate the effectiveness of self-efficacy interventions in improving mental HRQoL in patients with faecal incontinence.
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Affiliation(s)
- C Grano
- Department of Psychology, Sapienza University of Rome, Rome, Italy
| | - M Fernandes
- Department of Psychology, Sapienza University of Rome, Rome, Italy
| | - S Bucci
- Italian Parents and Patients Organization for Anorectal Malformation (AIMAR), Rome, Italy
| | - D Aminoff
- Italian Parents and Patients Organization for Anorectal Malformation (AIMAR), Rome, Italy
| | - F Lucidi
- Department of Developmental and Social Psychology, Sapienza University of Rome, Rome, Italy
| | - C Violani
- Department of Psychology, Sapienza University of Rome, Rome, Italy
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Long-term follow-up of anorectal malformation – how long is long term? ANNALS OF PEDIATRIC SURGERY 2018. [DOI: 10.1097/01.xps.0000529797.96055.cc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Challenges in Transition of Care for Patients With Anorectal Malformations: A Systematic Review and Recommendations for Comprehensive Care. Dis Colon Rectum 2018; 61:390-399. [PMID: 29420431 DOI: 10.1097/dcr.0000000000001033] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Anorectal malformations are one of the most common congenital intestinal anomalies affecting newborns. Despite advances in neonatal care and surgical techniques, many patients with a history of anorectal malformations are affected by long-term challenges involving bowel and bladder dysfunction, sexual dysfunction, and psychosocial issues. These outcomes or challenges are additionally exacerbated by the lack of a structured transition of care from the pediatric to the adult setting. OBJECTIVE The purpose of this review is to describe the long-term outcomes affecting patients with a history of anorectal malformations, review the current literature on transition of care, and make recommendations for developing a standardized program for transitioning care for a select group of colorectal surgical patients. DATA SOURCES An extensive PubMed review of articles in English was performed to evaluate current best practices for chronic illnesses of childhood with residual symptoms or need for medical care into adulthood. STUDY SELECTION Meta-Analysis of Observational Studies in Epidemiology group guidelines were followed. MAIN OUTCOME MEASURES The primary outcome for this review was the existence of transitional services for patients with a history of anorectal malformations and evaluations of long-term outcomes affecting patients with a history of anorectal malformations. RESULTS Systematic review revealed improved results in transition programs as determined by patient follow-up, medication adherence, and patient and family satisfaction through the use of multidisciplinary teams. Standardized tools for assessing all aspects of patient outcomes and quality of life are essential for describing the burden of disease affecting a transitioning population. LIMITATIONS This is a retrospective review of the current status of a complex and rapidly evolving field of delivery of care. More work is needed to apply uniform approaches and assess the impact, patient outcomes, and quality of life. CONCLUSIONS Patients who undergo childhood procedures for anorectal malformations often experience chronic symptoms related to the bowel, bladder, and reproductive organs, as well as psychosocial disturbances. This population will benefit from appropriate engagement in transitional care plans. See Video Abstract at http://links.lww.com/DCR/A543.
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Diseth TH, Emblem R. Long-term psychosocial consequences of surgical congenital malformations. Semin Pediatr Surg 2017; 26:286-294. [PMID: 29110824 DOI: 10.1053/j.sempedsurg.2017.09.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Surgical congenital malformations often represent years of treatment, large number of hospital stays, treatment procedures, and long-term functional sequels affecting patients' psychosocial functioning. Both functional defects and psychosocial difficulties that occur commonly in childhood may pass through adolescence on to adulthood. This overview presents reports published over the past 3 decades to elucidate the long-term psychosocial consequences of surgical congenital malformations. Literature searches conducted on PubMed database revealed that less than 1% of all the records of surgical congenital malformations described long-term psychosocial consequences, but with diverse findings. This inconsistency may be due to methodological differences or deficiencies; especially in study design, patient sampling, and methods. Most of the studies revealed that the functional deficits may have great impact on patients' mental health, psychosocial functioning, and QoL; both short- and long-term negative consequences. Factors other than functional problems, e.g., repeated anesthesia, multiple hospitalization, traumatic treatment procedures, and parental dysfunctioning, may also predict long-term mental health and psychosocial functioning. Through multidisciplinary approach, pediatric surgeons should also be aware of deficits in emotional and psychosocial functioning. To achieve overall optimal psychosocial functioning, the challenge is to find a compromise between physically optimal treatment procedures and procedures that are not psychologically detrimental.
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Affiliation(s)
- Trond H Diseth
- Section for Psychosomatics and CL-child Psychiatry, Department of Clinical Neurosciences for Children, Division of Paediatric and Adolescent Medicine, Oslo University Hospital Rikshospitalet, Pb 4950 Nydalen, N-0424 Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
| | - Ragnhild Emblem
- Department of Paediatric Surgery, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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Raman VS, Agarwala S, Bhatnagar V. Correlation between Quality of Life and Functional Outcomes in Operated Children with Anorectal Malformations Using the Krickenbeck Consensus. Indian J Pediatr 2017; 84:177-182. [PMID: 27928719 DOI: 10.1007/s12098-016-2269-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 11/22/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To correlate the functional outcomes in children operated for anorectal malformations (ARM) using the Krickenbeck consensus and their quality of life (QOL). METHODS Thirty-three children operated at a tertiary care Pediatric surgery centre were studied 2 y after completion of all the surgeries and if more than 3 y of age. The functional stooling outcomes, type of anomalies and surgical procedures were tabulated using the Krickenbeck classification. The QOL questionnaire consisted of five parameters (Social habit, school attendance, daily activity, relation to peers and feeling) and the scoring ranged between 0 and 12: Good (8-12), Fair (5-7) and Poor (0-4). RESULTS Median age of the children at the time of study was 7 y (Range 4-14). Comparison of stooling outcomes and QOL showed no significant difference (p 0.48). QOL was not affected by the age at evaluation, type of anomaly and type of surgical procedure. Children with vertebral, anorectal, cardiac, tracheoesophageal, radial and limb abnormalities (VACTERL) association had poorer QOL as compared to children without VACTERL association (p 0.02). Poor stooling outcomes were seen in children who underwent abdominoperineal pull through procedure (p 0.02). CONCLUSION QOL appears to be independent of the stooling outcomes in operated children of ARM with majority enjoying a good QOL (93.9%).
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Affiliation(s)
- V Shankar Raman
- Department of Pediatric Surgery, All Indian Institute of Medical Sciences, New Delhi, India. .,Department of Pediatric Surgery, Army hospital R&R, New Delhi, 110010, India.
| | - Sandeep Agarwala
- Department of Pediatric Surgery, All Indian Institute of Medical Sciences, New Delhi, India
| | - Veereshwar Bhatnagar
- Department of Pediatric Surgery, All Indian Institute of Medical Sciences, New Delhi, India
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Health-Related Quality of Life and Parental Stress in Children With Fecal Incontinence: A Normative Comparison. J Pediatr Gastroenterol Nutr 2016; 63:633-636. [PMID: 27027905 DOI: 10.1097/mpg.0000000000001201] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE The aim of the present study was to describe the quality of life and parenting stress associated with a child with fecal incontinence (FI). METHODS Female caregivers (n = 170) of children of 3 to 12 years age with FI completed a broad and general measure of quality of life and a measure of parenting stress. Results were compared with proxy reports for a normative sample of healthy children. RESULTS Caregivers of children with FI reported significantly impaired quality of life for their children and increased parenting stress in all of the respective domains relative to healthy controls. Impairments reported by caregivers were large in magnitude. Similarly, rates of parenting stress were at or greater than the 98th percentile for caregivers of children with FI. CONCLUSIONS Children with fecal incontinence and their families are in need of interventions targeting their quality of life and the stress associated with caregiving. FI appears to be particularly stressful for caregivers who may be in need of support beyond medical management of their child's bowel. Moreover, additional refinements in disease-specific quality of life assessment are needed in this population. Such refinement would allow for more precise measurement of the quality of life processes that are unique to FI.
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Bowel functional outcomes in females with perineal or vestibular fistula treated with anterior sagittal anorectoplasty: controlled results into adulthood. Dis Colon Rectum 2015; 58:97-103. [PMID: 25489700 DOI: 10.1097/dcr.0000000000000239] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Anterior sagittal anorectoplasty is a standardized operative treatment for females with congenital rectoperineal or vestibular fistula. The controlled, long-term outcomes require characterization. OBJECTIVE The aim of this study was to define the bowel functional outcomes following anterior sagittal anorectoplasty in relation to age- and sex-matched controls. DESIGN This cross-sectional study was conducted at a single institution. PATIENTS All females treated for congenital perineal or vestibular fistula with anterior sagittal anorectoplasty between 1983 and 2006 were invited to answer a detailed, previously validated questionnaire on bowel function. Each patient was matched to 3 controls who had answered identical questionnaires. Ethical approval was obtained. Social continence was defined as soiling or fecal accidents <1/week and no requirement for changes of underwear or protective aids. SETTING This study was conducted at the Hospital for Children and Adolescents, University of Helsinki, Finland. INTERVENTIONS No interventions were performed. MAIN OUTCOME MEASURES The primary outcomes measured were the prevalence of problems with rectal sensation, voluntary bowel control, soiling, fecal accidents, constipation, and social problems. Bowel function score (out of 20 items) was considered, as well as the age at completion of toilet training for stool. RESULTS Of 34 respondents (79%; median age, 13 (4-28) years), all had voluntary bowel movements. Problems withholding defecation, soiling, and fecal accidents were significantly more common among patients than controls (p ≤ 0.001). Eighty-five percent of patients and 100% of controls (p = 0.001) were socially continent; 41% of patients and 76% of controls were totally continent (p = 0.0003). Constipation tended to decline with age (from 59% to 25%; p = 0.16). The bowel functional outcome was good in 68% of patients, satisfactory in 26% of patients, and poor in 6% of patients. Diapers for stool had been discontinued at the same median age as controls. LIMITATIONS Number of patients in comparative analysis of symptoms by age group. CONCLUSIONS After anterior sagittal anorectoplasty for perineal or vestibular fistula, 2 of 3 of patients are likely to achieve bowel control comparable to normal in the long term, and the vast majority will be socially continent. The effective treatment of constipation is essential.
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Kyrklund K, Pakarinen MP, Koivusalo A, Rintala RJ. Long-term bowel functional outcomes in rectourethral fistula treated with PSARP: controlled results after 4-29 years of follow-up: a single-institution, cross-sectional study. J Pediatr Surg 2014; 49:1635-42. [PMID: 25475809 DOI: 10.1016/j.jpedsurg.2014.04.017] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Revised: 03/24/2014] [Accepted: 04/27/2014] [Indexed: 12/29/2022]
Abstract
BACKGROUND/PURPOSE Posterior sagittal anorectoplasty (PSARP) has become the standard surgical treatment for males rectourethral fistula (RUF) at most surgical centers worldwide. We aimed to define the long-term bowel functional outcomes following PSARP for RUF at our institution between 1983 and 2006, with comparison to age- and gender-matched controls. METHODS Patients were invited to answer a detailed, previously validated Bowel Function Score (BFS) questionnaire by post. Respondents were matched by age and gender to three controls from the general population who had answered identical questionnaires. Case records were reviewed retrospectively for operative details. Ethical approval was obtained. Social continence was defined as soiling or fecal accidents <1/week and no requirement for changes of underwear or protective aids. RESULTS Of 34 (79%) respondents (median age 19 (range, 4-29) years), 74% had voluntary bowel movements (VBMs), 24% were reliant on anterograde continence enema (ACE) washouts, and 1 patient had a colostomy. Impairment of bowel function was significantly higher in all aspects of fecal control among patients than controls (p<0.001). A statistically significant decline in fecal accidents and soiling was observed with age (p ≤ 0.03). Thirty-one percent of patients with VBMs had constipation managed with diet or laxatives (vs 2% of controls, p=0.0002). Of patients with VBMs followed up for > 12 years (n=20), 50% were completely continent (vs 73% of controls; p=NS). Overall, 76% of respondents were socially continent with or without artificial means in the form of ACE washouts. By BFS score, 39% had a good functional outcome, 27% had a moderate outcome, 9% had a clearly poor score and 24% were living with an ACE. CONCLUSIONS Our results suggest that in the long-term, functional symptoms remain highly prevalent among patients treated for RUF with PSARP. However, the majority can be expected to achieve social continence, although for some this will require intervention with ACE bowel management. Approximately one third may report VBMs and complete continence.
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Affiliation(s)
- Kristiina Kyrklund
- Department of Pediatric Surgery, Hospital for Children and Adolescents, University of Helsinki, Helsinki, Finland.
| | - Mikko P Pakarinen
- Department of Pediatric Surgery, Hospital for Children and Adolescents, University of Helsinki, Helsinki, Finland
| | - Antti Koivusalo
- Department of Pediatric Surgery, Hospital for Children and Adolescents, University of Helsinki, Helsinki, Finland
| | - Risto J Rintala
- Department of Pediatric Surgery, Hospital for Children and Adolescents, University of Helsinki, Helsinki, Finland
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Outcome of patients with anorectal malformations after posterior sagittal anorectoplasty. ANNALS OF PEDIATRIC SURGERY 2014. [DOI: 10.1097/01.xps.0000450388.28994.70] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Eradi B, Hamrick M, Bischoff A, Frischer JS, Helmrath M, Hall J, Peña A, Levitt MA. The role of a colon resection in combination with a Malone appendicostomy as part of a bowel management program for the treatment of fecal incontinence. J Pediatr Surg 2013; 48:2296-300. [PMID: 24210202 DOI: 10.1016/j.jpedsurg.2013.03.058] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Revised: 03/07/2013] [Accepted: 03/17/2013] [Indexed: 11/24/2022]
Abstract
PURPOSE Surgical options previously described by us as part of a bowel management program for the treatment of soiling and fecal incontinence include (1) resection of a megarectosigmoid to reduce a patient's laxative requirement or (2) a Malone appendicostomy in patients who require enemas. We have found that some patients may benefit from both procedures. METHODS We reviewed 18 fecally incontinent patients with structural or functional disorders of the anorectosigmoid (16 ARM, 1 spina bifida, and 1 SCT) who underwent both procedures. RESULTS Of 18 patients, the enema regimen prior to resection had an average volume of 681 ml of saline (Range 400-1000 ml) and 60 ml (Range 48-117 ml) of additives (glycerine, castile soap and/or phosphate). Following the colon resection, the average volume of saline and additives was 335 ml (Range 130-650 ml) and 25 ml (Range 0-60 ml), respectively, a 50% reduction for both (P<0.01). The time for enema administration and evacuation was reduced by 25%, and the enemas were more effective, rendering the patients clean in 18 of 18 cases (follow-up was 3 months to 21 years). 2 patients later demonstrated that they could be managed with laxatives alone. CONCLUSION In patients with poor continence potential and a megarectosigmoid, combining a colon resection with a Malone appendicostomy can make the enema more effective. In some rare cases we found the resection may allow for a better response to laxatives.
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Affiliation(s)
- Balgopal Eradi
- Division of Pediatric Surgery, Colorectal Center for Children, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
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Grano C, Bucci S, Aminoff D, Lucidi F, Violani C. Does mothers' perception of social support mediate the relationship between fecal incontinence and quality of life of the child? Pediatr Surg Int 2013; 29:919-23. [PMID: 23913264 DOI: 10.1007/s00383-013-3358-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE Fecal incontinence is a common problem in children and adolescents with anorectal malformation (ARM) and may negatively impact psycho-social well-being. Mothers' perception of social support has been proved to contribute to children's quality of life (QOL). Considering ARM studies, the role of family and social resources have received little attention. The aim of the present study was to analyze whether mothers' perception of social support mediates the impact of child fecal incontinence on his/her QOL. METHODS One hundred and nine mothers with a child born with ARM (aged 6-15 years old; mean age = 11 years) completed questionnaires including the fecal incontinence subscale of the Hirschsprung's Disease/Anorectal Malformation QOL Questionnaire, the Pediatric QOL Inventory, and a social relationship questionnaire. Structural equation models were used to explore the relations hypothesized. RESULTS No differences were found in the QOL scores across gender. The hypothesized model fits the data well; mothers' perception of social support partially mediated the relationship between fecal incontinence and QOL. CONCLUSIONS An important direction for pediatric surgeons and their interdisciplinary teams may be to develop strategies to strengthen mothers' social relationships.
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Affiliation(s)
- Caterina Grano
- Italian Parents and Patients Organization for Anorectal Malformation (AIMAR), Via Tripolitania, 211, 00199 Rome, Italy.
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26
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Athanasakos EP, Kemal KI, Malliwal RS, Scott SM, Williams NS, Aziz Q, Ward HC, Knowles CH. Clinical and psychosocial functioning in adolescents and young adults with anorectal malformations and chronic idiopathic constipation. Br J Surg 2013; 100:832-9. [PMID: 23553758 DOI: 10.1002/bjs.9111] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND Faecal incontinence (FI) and constipation occur following corrective surgery for anorectal malformations (ARMs) and in children or adults with chronic constipation without a structural birth anomaly (chronic idiopathic constipation, CIC). Such symptoms may have profound effects on quality of life (QoL). This study systematically determined the burden of FI and constipation in these patients in adolescence and early adulthood, and their effect on QoL and psychosocial functioning in comparison with controls. METHODS Patients with ARMs or CIC were compared with age- and sex-matched controls who had undergone appendicectomy more than 1 year previously and had no ongoing gastrointestinal symptoms. Constipation and FI were evaluated using validated Knowles-Eccersley-Scott Symptom (KESS) and Vaizey scores respectively. Standardized QoL and psychometric tests were performed in all groups. RESULTS The study included 49 patients with ARMs (30 male, aged 11-28 years), 45 with CIC (32 male, aged 11-30 years) and 39 controls (21 male, aged 11-30 years). The frequency of severe constipation among patients with ARMs was approximately half that seen in the CIC group (19 of 49 versus 31 of 45); however, frequencies of incontinence were similar (22 of 49 versus 21 of 45) (P < 0·001 versus controls for both symptoms). Physical and mental well-being were significantly reduced in both ARM and CIC groups compared with controls (P = 0·001 and P = 0·015 respectively), with generally worse scores among patients with CIC. Both were predicted by gastrointestinal symptom burden (P < 0·001). There were no statistically significant differences in state or trait psychiatric morbidity between groups. CONCLUSION FI and constipation are major determinants of poor QoL in adolescents and young adults with ARMs and in those with CIC.
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Affiliation(s)
- E P Athanasakos
- Department of Paediatric Surgery, Barts Health NHS Trust, The Royal London Hospital, London, UK
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Borg HC, Holmdahl G, Gustavsson K, Doroszkiewicz M, Sillén U. Longitudinal study of bowel function in children with anorectal malformations. J Pediatr Surg 2013; 48:597-606. [PMID: 23480919 DOI: 10.1016/j.jpedsurg.2012.10.056] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Revised: 09/18/2012] [Accepted: 10/22/2012] [Indexed: 11/18/2022]
Abstract
PURPOSE Longitudinal follow-up of changes in bowel function in children with anorectal malformations (ARMs) with or without spinal cord pathology and neurogenic bladder dysfunction (NBD) as they grow. Another purpose was to identify predictors influencing bowel functional outcome. MATERIAL AND METHODS The study included 41 patients with ARM, excluding perineal fistula (21 boys and 20 girls). Bowel function was evaluated at ages 5, 10 and 15 years using a structured questionnaire and a three-week registration of number and time of bowel movements, episodes of fecal leakage and soiling. Additional bowel treatment with enemas and stool softeners and use of diapers were recorded. A group of 52 healthy boys and girls was used as control. RESULTS A successive improvement in functional outcome with age in children with ARM and normal spinal cord was seen with respect to continence, soiling and constipation. Continence was achieved earlier in girls than in boys (at 10 years: girls 80%, boys 36%). Soiling and constipation decreased with age both in grade and frequency (at 10 years low grade soiling: girls 53%, boys 64%). Boys with spinal cord malformation with NBD in combination with prostatic/bladder neck fistula (PRF/BNF) and sacral agenesis had the worst functional outcome with minimal possibility of improvement over time. Functional outcome in girls with NBD and tethered cord did not differ significantly from those without NBD and with a normal spinal cord. Psychosocial co-morbidity, neuropsychiatric disorders, developmental delay and megarectosigmoid were also risk factors impeding the functional outcome. CONCLUSION In the present study there was a successive improvement in bowel function during childhood and adolescence in ARM children, but they did not achieve the level of healthy children. NBD, spinal cord malformation, sacral malformation and PRF all were negative predictive factors for bowel score at 5 years.
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Affiliation(s)
- Helena C Borg
- Department of Pediatric Surgery, The Queen Silvia Children's Hospital, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.
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Witvliet MJ, Slaar A, Heij HA, van der Steeg AFW. Qualitative analysis of studies concerning quality of life in children and adults with anorectal malformations. J Pediatr Surg 2013; 48:372-9. [PMID: 23414868 DOI: 10.1016/j.jpedsurg.2012.11.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Accepted: 11/12/2012] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Anorectal malformations are relatively common congenital anomalies in pediatric surgery. After definitive surgery constipation, soiling, and fecal incontinence are frequently seen problems. Quality of life (QoL) can be influenced by these problems. In the last decades QoL has become an important aspect in the treatment and follow-up of patients with anorectal malformations. This has resulted in various reports concerning QoL. In order to deduce whether the drawn conclusions in the different studies are correct and can be used to adjust standard care for patients with ARM, a qualitative analysis of the studies was performed. MATERIAL AND METHODS A literature study was performed in PubMed, Psychinfo, Web of Science, and the Cochrane Library (240 hits). Thirty articles were used, following application of our inclusion criteria and in-depth analysis of the articles. A methodological qualitative analysis was also performed and QoL outcome assessed. RESULTS Six authors (20.0%) used validated QoL questionnaires. Four articles were longitudinal and had more than one measure moment. Eleven studies (36.7%) used only non-validated questionnaires, and eight studies (26.6%) used only validated questionnaires. Nineteen studies correlated fecal continence to QoL, and seven studies established no correlation. Three of these seven studies used validated QoL questionnaires. All twelve studies, which did establish a correlation, used non-validated QoL questionnaires. CONCLUSIONS Approximately 83% of the studies had not used validated QoL questionnaires. Further, conclusions concerning QoL were often based on functional outcomes, for example fecal incontinence. So far, longitudinal high quality research on QoL in this group has not been achieved.
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Affiliation(s)
- Marieke J Witvliet
- Pediatric Surgical Center of Amsterdam, Emma Children's Hospital AMC and VU University Medical Center, Amsterdam, The Netherlands
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Melo MC, Kamada I. [Anorectal anomaly and maternal care]. Rev Bras Enferm 2011; 64:176-9. [PMID: 21468506 DOI: 10.1590/s0034-71672011000100025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2009] [Accepted: 09/12/2010] [Indexed: 11/22/2022] Open
Abstract
This purpose of the article was to make a bibliographic review about anorectal malformations and maternal cares. The matter was addressed through an integrative review undertaken in consultation of articles published in the databases indexed in the Virtual Health Library. We identified 25 publications that met the inclusion and exclusion criteria pre-established. In the studies reviewed, there were different study designs, demonstrating that some children born with anorectal anomalies requiring urgent surgery. Health professionals, along with the parents, need to develop partnerships that would enable a long-term monitoring and careful guidance. It is necessary to do more research on the subject, with methodological proposals that reflect the essence of the best care of an ostomized child.
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Affiliation(s)
- Manuela Costa Melo
- Departamento de Enfermagem, Escola Superior em Ciências da Saúde, Universidade de Brasília, Brasília, DF.
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Grano C, Aminoff D, Lucidi F, Violani C. Long-term disease-specific quality of life in adult anorectal malformation patients. J Pediatr Surg 2011; 46:691-698. [PMID: 21496539 DOI: 10.1016/j.jpedsurg.2010.10.016] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2010] [Revised: 10/11/2010] [Accepted: 10/17/2010] [Indexed: 11/19/2022]
Abstract
BACKGROUND Fecal and urinary incontinence may differently influence various aspects of quality of life (QOL). The main aim of the present study is to determine whether fecal and urinary incontinence measured at time 1 of the study will predict QOL at time 2 (after 4 years), above and beyond the prediction already explained by fecal and urinary incontinence at time 2. METHODS Thirty-six adult patients from the Italian Parents' and Patients' Association for Anorectal Malformations answered items about urinary and fecal incontinence at time 1 of the study and completed the Hirschsprung Disease/Anorectal Malformation Quality of Life questionnaire after 4 years from the first questionnaire. Two sets of hierarchical regression analyses were conducted with fecal and urinary incontinence serving as predictors of QOL and the different areas of QOL from the Hirschsprung Disease/Anorectal Malformation Quality of Life serving as outcome variables. RESULTS The principal findings indicated that fecal continence is a strong predictor of QOL in the areas of social functioning, emotional functioning, and body image and that urinary incontinence predicted sexual functioning. CONCLUSIONS It seems that one's past experience with fecal incontinence is extremely relevant to current QOL, especially for body image. Urinary incontinence contributed less in explaining QOL in our patients, but because it is very relevant for sexual functioning, it should not be disregarded.
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Affiliation(s)
- Caterina Grano
- Department of Psychology, University of Rome "La Sapienza," 00185 Rome, Italy.
| | - Dalia Aminoff
- Italian Parents and Patients Organization for Anorectal Malformation (AIMAR), 00199 Rome, Italy.
| | - Fabio Lucidi
- Department of Social and Development Psychology, University of Rome "La Sapienza," 00185 Rome, Italy.
| | - Cristiano Violani
- Department of Psychology, University of Rome "La Sapienza," 00185 Rome, Italy.
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Kaselas C, Philippopoulos A, Petropoulos A. Evaluation of long-term functional outcomes after surgical treatment of anorectal malformations. Int J Colorectal Dis 2011; 26:351-6. [PMID: 21057799 DOI: 10.1007/s00384-010-1081-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/21/2010] [Indexed: 02/04/2023]
Abstract
PURPOSE The aim of this study was to evaluate the long-term functional outcome in children with anorectal malformations and to correlate them with the type of malformation METHODS The medical files of children treated for anorectal malformation from 1996 to 2007 were retrospectively reviewed. Data collected included age, gender, type of ARM, associated malformations, type of initial approach, definitive operation, and post-operative management. A multivariate scoring method for fecal continence has been used for evaluation of functional outcome score. RESULTS Thirty one patients were initially included in the study. Twenty eight of them were evaluated for long-term functional outcomes (mean age 7.25 ± 0.52 years, males 7.96 ± 0.68 years, female 6.46 ± 0.76 years). The mean functional outcome score of all patients was significantly lower compared to that of sex- and age-matched healthy controls (13.92 ± 0.59 to 19.76 ± 0.08, p < 0.0001). No statistical significance was found between the mean functional outcome and the patients' age, gender, or associated anomaly. CONCLUSION The functional outcome score can be considered as an index of management of defecation disorders in children with anorectal malformation. The long-term functional outcome in children with anorectal malformations is significantly lower than normal controls. Regular follow-ups are required in order to offer them a socially accepted day life.
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Affiliation(s)
- Christos Kaselas
- Second Department of Pediatric Surgery, Aristotle University of Thessaloniki Medical School, Papageorgiou University General Hospital, Ring Road Nea Efkarpia, 56403 Thessaloniki, Greece.
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Senel E, Akbiyik F, Atayurt H, Tiryaki HT. Urological problems or fecal continence during long-term follow-up of patients with anorectal malformation. Pediatr Surg Int 2010; 26:683-9. [PMID: 20505942 DOI: 10.1007/s00383-010-2626-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/16/2010] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Anorectal malformations comprise a wide spectrum of diseases. The main concerns for the surgeon in correcting these anomalies are bowel control, urinary control, and sexual function. The aim of this study was to evaluate fecal continence together with additional urinary anomalies in patients with anorectal malformations (ARM) and determine which of them is more troublesome for life quality in long-term follow-up. MATERIALS AND METHODS A total of 93 cases followed up and treated at our clinic between 1983 and 2009 were evaluated for urinary pathologies, fecal continence, and their quality of life (QOL). Patients were classified according to the international system (Krickenbeck), and were evaluated on the basis of voluntary bowel movement, constipation, and fecal soiling. They were also classified as good, fair, and poor regarding fecal continence. The urinary system pathologies, the medical and surgical treatments received, and the pediatric nephrology follow-up results were all evaluated. The patients were grouped by age and their QOL scored using a telephone interview. RESULTS The mean age (+/-SD) was 8.47 +/- 4.85 (3-25) years, and the mean follow-up period was 6.96 +/- 4.55 (1-23) years. Evaluation of the patients in relation to their fecal continence revealed that 35 (37.6%) had constipation, 22 (23.6%) had fecal soiling, and voluntary bowel movements were absent in 7 (7.5%). Fecal continence was evaluated using the Krickenbeck classification, and it was good in 74 (79.6%), fair in 12 (12.9%), and poor in 7 (7.5%). QOL evaluation of these cases showed markedly decreasing QOL as the cases changed from good to poor fecal continence. Urinary system pathology was detected in 35 (37.6%) of the cases with 22 (23.7%) having severe uropathology. We compared the 22 patients with severe uropathology and 71 cases without severe uropathology for QOL and found the ARM group with severe uropathology to have significantly lower physical QOL, psychosocial QOL, and total QOL values. Reviewing the patients by fecal continence and urinary pathologies together regarding QOL showed that patients with good fecal continence and no additional urinary abnormality had the best QOL. The QOL decreased considerably in both the group with a fecal incontinence problem but no additional urinary abnormality and the group with good fecal continence but serious additional urinary abnormality. The QOL was worst in patients with urinary pathology and fecal incontinence. DISCUSSION Anorectal malformations constitute a wide spectrum of disease. Urinary anomalies and their complications significantly increase the morbidity in these children even after the correction of the ARM. In the evaluation of the published series, we noted that the main issue was fecal continence, and there was not enough data concerning the urinary system pathologies of the patients when they reach adult ages. Anorectal dysfunction has a negative effect on QOL in ARM patients, but is not life threatening. Such patients can lead normal life although the QOL is affected. However, vesicoureteral dysfunction can cause permanent damage in other organs. This damage may cause mortality depending on the level of the malformation. Evaluating the patients considering fecal continence and urinary system pathology together showed that nearly 10% of the ARM patients had serious problems affecting their long-term QOL related to fecal control, whereas nearly a fourth of the cases had additional anomalies of the urinary system that will affect the QOL despite all treatments used, as the development of pyelonephritis, hypertension, and end-stage renal disease should be expected in these patients. CONCLUSION Urinary system anomalies in patients with ARM are at least as serious and complex as gastrointestinal system anomalies and create more problems than fecal incontinence during long-term follow-up.
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Affiliation(s)
- Emrah Senel
- Department of Pediatric Surgery, Diskapi Children's Hospital, Ankara, Turkey.
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Hashish MS, Dawoud HH, Hirschl RB, Bruch SW, El Batarny AM, Mychaliska GB, Drongowski RA, Ehrlich PF, Hassaballa SZ, El-Dosuky NI, Teitelbaum DH. Long-term functional outcome and quality of life in patients with high imperforate anus. J Pediatr Surg 2010; 45:224-30. [PMID: 20105608 DOI: 10.1016/j.jpedsurg.2009.10.041] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2009] [Accepted: 10/06/2009] [Indexed: 11/29/2022]
Abstract
PURPOSE Anorectal malformations (ARMs) are associated with a large number of functional sequale that may affect a child's long-term quality of life (QOL). The purposes of this study were to better quantify patient functional stooling outcome and to identify how these outcomes related to the QOL in patients with high imperforate anus. METHODS Forty-eight patients from 2 children's hospitals underwent scoring of stooling after 4 years of life. Scoring consisted of a 13-item questionnaire to assess long-term stooling habits (score range: 0-30, worst to best). These results were then correlated with a QOL survey as judged by a parent or guardian. RESULT Mean (SD) age at survey was 6.5 (1.6) years. Comparison of QOL and clinical scoring showed no signficant difference between the 2 institutions (P > .05). There was a direct correlation between the QOL and stooling score (Pearson r(2) = 0.827; beta coefficient = 24.7, P < .001). Interestingly, functional stooling scores worsened with increasing age (Pearson r(2) = 0.318, P = .02). Patients with associated congenital anomalies had a high rate of poor QOL (44% in poor range; P = .001). Stooling scores decreased significantly with increasing severity/complexity of the ARM (P = .001). CONCLUSION A large number of children experience functional stooling problems, and these were directly associated with poor QOL. In contrast to previous perceptions, our study showed that stooling patterns are perceived to worsen with age. This suggests that children with ARMs need long-term follow-up and counseling.
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Affiliation(s)
- Mohamed S Hashish
- Section of Pediatric Surgery, Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
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Zhang J, Zhang ZB, Gao H, Zhang D, Wang WL. Down-Regulation of SHH/BMP4 Signalling in Human Anorectal Malformations. J Int Med Res 2009; 37:1842-50. [PMID: 20146882 DOI: 10.1177/147323000903700620] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
The sonic hedgehog homologue (SHH)/bone morphogenetic protein 4 (BMP4) signalling pathway is involved in the morphogenesis of many organ systems. This study was designed to investigate the expression of SHH/BMP4 pathway components in human anorectal malformations (ARMs) and the relationship between expression of their genes and the occurrence of ARMs. Expression of SHH, GLI family zinc finger 2 (GLI2) and BMP4 mRNA in the posterior wall of the terminal rectum in 40 patients with ARMs (15 high-type and 25 low-type) and 10 normal controls was assessed by reverse transcription-polymerase chain reaction. Levels of SHH, GLI2 and BMP4 proteins were assessed by immunohistochemistry and Western blotting. The expressions of SHH, GLI2 and BMP4 were significantly lower in patients with high-type compared with those with low-type anomalies and controls. Patients with low-type ARMs differed from controls only in the expression of GLI2 mRNA. It is concluded that down-regulation of the SHH/BMP4 signalling pathway may be related to the occurrence of high-type ARMs, but the mechanism responsible for low-type ARMs remains unclear.
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Affiliation(s)
- J Zhang
- Department of Paediatric Surgery, Shengjing Hospital, China Medical University, Shenyang, China
| | - ZB Zhang
- Department of Paediatric Surgery, Shengjing Hospital, China Medical University, Shenyang, China
| | - H Gao
- Department of Paediatric Surgery, Shengjing Hospital, China Medical University, Shenyang, China
| | - D Zhang
- Department of Paediatric Surgery, Shengjing Hospital, China Medical University, Shenyang, China
| | - WL Wang
- Department of Paediatric Surgery, Shengjing Hospital, China Medical University, Shenyang, China
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Gischler SJ, Mazer P, Duivenvoorden HJ, van Dijk M, Bax NMA, Hazebroek FWJ, Tibboel D. Interdisciplinary structural follow-up of surgical newborns: a prospective evaluation. J Pediatr Surg 2009; 44:1382-9. [PMID: 19573666 DOI: 10.1016/j.jpedsurg.2008.12.034] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2008] [Revised: 10/22/2008] [Accepted: 12/29/2008] [Indexed: 01/18/2023]
Abstract
BACKGROUND Information on physical and developmental outcomes of children with anatomical congenital anomalies (CAs) may indicate the need for early intervention and reduce impact on the child's life and parental burden. METHODS From 1999 to 2003, 101 children with CA (76.5% of initial survivors) were seen 6-monthly in a tertiary children's hospital. Growth, neurologic outcome, mental and psychomotor development as determined with the Bayley Scales of Infant Development, and categorization of predictive sociodemographic and medical variables of the children were evaluated prospectively and longitudinally. RESULTS Congenital diaphragmatic hernia (CDH) and esophageal atresia patients showed impaired growth, that is, both height for age (-1.5 standard deviation score [SDS]) and weight for height (-1.0 SDS). Overall neurologic outcome was normal, however, suspect or abnormal for 40% of CDH patients. Overall mental development was normal, but psychomotor scores were significantly lower than the norm (95% confidence interval, 83.8-92.2 at 6 months and 87.9-98.5 at 24 months). Sex, maternal age, socioeconomic status, CA, severity-of-disease covariables, and need of medical appliances at home could predict negative outcome significantly (P < .05). CONCLUSIONS The CA survivors show impaired growth and psychomotor developmental delay up to age 2 years. This warrants specific follow-up programs and infrastructure for these patients.
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Affiliation(s)
- Saskia J Gischler
- Surgical Intensive Care Unit, Department of Pediatric Surgery, Erasmus MC, Sophia Children's Hospital, Erasmus University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands
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Abstract
INTRODUCTION Several studies indicate that self-efficacy may have profound positive effects on health promotion, clinical practice and other outcomes, like patients' satisfaction and quality of life. However no studies on self-efficacy have been conducted in anorectal malformation (ARM) patients. Aim of the present study is to analyze the relationships between self-efficacy and satisfaction with postoperative care in ARM patients or in their parents and between self-efficacy, body image and sexual functioning in adult ARM patients. MATERIAL AND METHODS A total of 237 patients from 2 to 49 years old (mean age = 13.35 years old) participated in the study. Questionnaires were sent to members of the Italian Association for Anorectal Malformation (AIMAR) by ordinary mail. All subjects were asked to fill in the AIMAR questionnaire in which information about the perceived severity of malformation and postoperative care satisfaction were collected. For patients under 16 years old, parents were asked to fill in a questionnaire and a parent self-efficacy scale concerning the perceived ability to overcome possible difficulties related to ARM. Participants above 16 years of age were asked to fill in the questionnaire, a self-efficacy scale and some body image and sexual functioning items. RESULTS The main findings indicate that those patients who feel more efficacious are those who feel less embarrassed and shame about their body, feel less frequently unsatisfied of their body and their physical condition, and have the perception to be less limited in their sexual activities. Considering patients under 16 years old, results indicate that more parents feel efficacious, the more they are satisfied of the postoperative care, especially of some health care providers. CONCLUSIONS In ARM patients self-efficacy and parents self efficacy are correlated to important outcomes, respectively body image and sexual functioning in adults and postoperative care satisfaction in parents of those under 16 years old. Future longitudinal studies are needed to evaluate causal relations between the concepts considered.
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Factors affecting quality of life of children and adolescents with anorectal malformations or Hirschsprung disease. J Pediatr Gastroenterol Nutr 2008; 47:463-71. [PMID: 18852639 DOI: 10.1097/mpg.0b013e31815ce545] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES First, to compare the quality of life (QL) and perceived self-competence of children and adolescents with anorectal malformations or Hirschsprung disease with that of reference groups. Second, to identify predictors of QL. PATIENTS AND METHODS A total of 491 patients with anorectal malformations or Hirschsprung disease were sent a questionnaire, which assessed QL (mental, physical), disease-specific functioning (defecation-related), perceived self-competence (self-esteem, athletic competencies, school attitude), and demographic characteristics (sex, age). The clinical characteristics (disease severity, presence of congenital anomalies) were extracted from medical records. RESULTS More than 50% (316, 64%) of patients with anorectal malformations or Hirschsprung disease completed the questionnaire. On average, children and adolescents in both patient groups reported no differences in QL domains compared with the reference groups. However, standard deviations revealed considerable individual variation, indicating the presence of patients with high levels of QL as well as patients with low levels of QL. Children and adolescents in both patient groups reported psychosocial problems in all domains, compared with the reference groups. Females, older patients, and those with a severe form of the disease reported lower levels of perceived self-competence and global disease-specific functioning, which in turn predicted QL. CONCLUSIONS Our results should alert clinicians to patients who are at risk for QL problems and may therefore be in need of extra care. Our findings illustrate the importance of both global disease-specific functioning and perceived psychosocial competencies for enhancing the QL of these patients.
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Ojmyr-Joelsson M, Christensson K, Frenckner B, Nisell M, Lindholm T. Children with high and intermediate imperforate anus: remembering and talking about medical treatment carried out early in life. Pediatr Surg Int 2008; 24:1009-15. [PMID: 18668253 DOI: 10.1007/s00383-008-2203-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/09/2008] [Indexed: 11/30/2022]
Abstract
Treatment of children with high and intermediate imperforate anus entails several different surgical procedures during the first 3-12 months of life, which are accompanied by a strict follow-up treatment regimen. It has not been studied whether the children remember this treatment carried out early in life. Research has shown that small children may demonstrate so-called non-verbal memories of salient events occurring in early childhood. The purpose was to examine whether children with imperforate anus showed distressing memories of previous medical treatment and whether parent-child dialog about medical treatment is related to the child's psychosocial functioning later in life. Parents of 25 children (9 boys, 16 girls) with high and intermediate imperforate anus participated in the study. The mean age among the children was 10.5 years (range 8.0-13.6). A comparison group of 30 children (5 boys and 25 girls) with juvenile chronic arthritis also participated in the study. The mean age was 10.6 years (range 7.8-13.6). All parents answered the Child Behavior Checklist (CBCL/4-18) and a study-specific questionnaire. Children in both groups were reported to show distressing memories of early treatment. Children who had been talked to showed good psychosocial function and were in a better mood and less angry than those who had not been talked to. Parent-child discussions about the child's experiences of medical treatment did not seem to be harmful or in any other way detrimental to the child, instead such discussions seemed to facilitate the child's psychosocial functioning.
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Affiliation(s)
- Maria Ojmyr-Joelsson
- Pediatric Surgery Unit, Department of Woman and Child Health, Karolinska Institutet, Stockholm, Sweden.
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Abstract
Outcomes are, simply put, why a surgeon comes to work each day. For decades, surgeons have insisted on a regular self-examination of outcomes to ensure the optimal treatment of our patients. Clinical research in pediatric surgery has largely subsisted on outcome analysis as it relates to the rudimentary end-result of an operation, utilizing variables such as mortality, operative time, specific complication rates, and hospital length of stay to name a few. Recently, outcomes research has become a more complex endeavor. This issue of Seminars in Pediatric Surgery addresses a wide array of these newfound complexities in contemporary outcomes research. The purpose of this review is to assist the pediatric surgeon in understanding the tools that are used in contemporary outcomes research and to be able to use this information to ask new questions of our patients and ourselves as we continue to strive for excellence in caring for sick infants and children.
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Affiliation(s)
- Casey M Calkins
- Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin 53226, USA.
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Mills JLA, Konkin DE, Milner R, Penner JG, Langer M, Webber EM. Long-term bowel function and quality of life in children with Hirschsprung's disease. J Pediatr Surg 2008; 43:899-905. [PMID: 18485963 DOI: 10.1016/j.jpedsurg.2007.12.038] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2007] [Accepted: 12/03/2007] [Indexed: 12/21/2022]
Abstract
BACKGROUND/PURPOSE Little is known about the quality of life (QOL) of children with Hirschsprung's disease (HD) as they grow older. The purpose of this study was to measure the QOL and bowel function of these children as they mature. METHODS All children who were surgically treated for HD at British Columbia Children's Hospital, Vancouver, British Columbia, Canada between 1986 and 2003 were invited to participate. Each family was sent 3 previously validated questionnaires exploring current QOL and bowel function. RESULTS Fifty-one families participated (49%), with children between the ages of 3 and 21 years. Fecal continence improved significantly with age (P = .04) and was the strongest predictor of QOL scores of all variables in our study. There was no statistically significant difference in QOL scores between children with HD and healthy children, although a clinically relevant impairment in QOL may be present, especially in psychosocial scores. CONCLUSIONS Fecal continence is an important predictor of overall QOL in children surgically treated for HD. Although continence tends to improve with age, a number of older children still have ongoing continence problems, and they seem to be a group at risk for impaired QOL. Our study indicates that interventions for children with incontinence may offer gains in QOL as well as bowel function.
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Affiliation(s)
- Jessica L A Mills
- Division of Pediatric General Surgery, British Columbia Children's Hospital and the University of British Columbia, Vancouver, British Columbia, Canada V6M 2L8
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Vital PF, Martins JL, Peterlini FL. Posterior sagittal anorectoplasty in anorectal anomalies: clinical, manometric and profilometric evaluation. SAO PAULO MED J 2007; 125:163-9. [PMID: 17923941 PMCID: PMC11020576 DOI: 10.1590/s1516-31802007000300007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2006] [Revised: 05/05/2006] [Accepted: 05/22/2007] [Indexed: 11/22/2022] Open
Abstract
CONTEXT AND OBJECTIVE Anorectal malformations comprise a spectrum of anomalies that continue to be difficult to treat, even today. The aim was to evaluate the fecal continence of children who underwent posterior sagittal anorectoplasty due to anorectal malformations, via computerized anorectal manometry and profilometry. DESIGN AND SETTING Prospective study at Universidade Federal de São Paulo. METHOD 82 patients (56.1% boys; 43.9% girls) of mean age 85.5 months were evaluated. They were divided into continent, partially continent and incontinent groups. Age, sex, manometric variables and profilometric parameters were studied. The results were statistically analyzed. RESULTS Among the 82 patients, 37.8% were continent, 25.6% were partially continent and 36.6% were incontinent. The overall mean resting pressure was 22 mmHg, and the means for the continent, partially continent and incontinent groups were, respectively, 30.7 mmHg, 23 mmHg and 14.7 mmHg. The overall mean pressure response to voluntary contraction was 56 mmHg, and the means for the groups were 65.4 mmHg, 55.8 mmHg and 46.6 mmHg, respectively. The rectosphincteric reflex was absent in 82.9% of the cases. In the profilometry analysis for all patients together, blue (20 to 50 mmHg) and yellow (50 to 80 mmHg) were predominant, and there was a similar distribution for the continent and partially continent patients. However, among the incontinent patients, green (< 20 mmHg) and blue prevailed. CONCLUSIONS Manometric and computerized profilometric analyses were an excellent method for postoperative evaluations on patients with intermediate and high anorectal anomalies, and for therapeutic planning.
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Affiliation(s)
| | - José Luiz Martins
- José Luiz Martins Rua dos Otonis, 131 — Vila Clementino São Paulo (SP) — Brasil — CEP 04025-000 Tel. (+55 11) 7100-0907 — Fax. (+55 11) 5575-4761 E-mail:
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