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Choueiki JM, Sales S, Callicott S, Ashman D, Worst K, Badillo A, Varda BK, Mayhew A, Xu TO, Levitt MA. Is Collaborative Care the Future of Medicine? Lessons Learned from the Care of Children with Colorectal Conditions. CHILDREN (BASEL, SWITZERLAND) 2024; 11:570. [PMID: 38790565 PMCID: PMC11119695 DOI: 10.3390/children11050570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 04/12/2024] [Accepted: 05/02/2024] [Indexed: 05/26/2024]
Abstract
The treatment of patients with colorectal disorders requires care from a wide variety of medical and surgical specialties over the course of their lifetime. This is ideally handled by a collaborative center which facilitates the assessment and development of patient care among multiple specialties which can enhance the quality and implementation of treatment plans, improve communication among different specialties, decrease morbidity, and improve patient satisfaction and outcomes. This collaborative approach can serve as a model for other parts of medicine requiring a similar multi-disciplinary and integrated method of care delivery. We describe the process, as well as the lessons learned in developing such a program.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Marc A. Levitt
- Division of Colorectal and Pelvic Reconstruction, Children’s National Hospital, Washington, DC 20010, USA; (J.M.C.); (S.S.); (S.C.); (D.A.); (K.W.); (A.B.); (B.K.V.); (T.O.X.)
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2
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Badillo A, Tiusaba L, Jacobs SE, Al-Shamaileh T, Feng C, Russell TL, Bokova E, Sandler A, Levitt MA. Sparing the Perineal Body: A Modification of the Posterior Sagittal Anorectoplasty for Anorectal Malformations with Rectovestibular Fistulae. Eur J Pediatr Surg 2023; 33:463-468. [PMID: 36356590 DOI: 10.1055/a-1976-3611] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND The posterior sagittal anorectoplasty (PSARP) used to repair an anorectal malformation (ARM) with a rectovestibular fistula involves incising the perineal body skin and the sphincter muscles and a posterior sagittal incision to the coccyx. Perineal body dehiscence is the most common and morbid complication post-PSARP which can have a negative impact on future bowel control. With consideration of all the other approaches described to repair this anomaly, we developed a perineal body sparing modification of the standard PSARP technique. METHODS Four patients with ARM with a rectovestibular fistula were repaired with a perineal body sparing modified PSARP at a single institution between 2020 and 2021. The incision used was limited, involving only the length of the anal sphincter, with no incision anterior or posterior to the planned anoplasty. Dissection of the distal rectum and fistula was performed without cutting the perineal body. Once the distal rectum was mobilized off the posterior vaginal wall and out of the vestibule, the perineal body muscles, where the fistula had been, were reinforced and an anoplasty was then performed. RESULTS Operative time was the same as for a standard PSARP. There were no intraoperative or postoperative complications. No postoperative dilations were performed. All patients healed well with an excellent cosmetic result. All are too young to assess for bowel control. CONCLUSION We present a new technique, a modification of the traditional PSARP for rectovestibular fistula, which spares the perineal body. This approach could eliminate the potential complication of perineal body dehiscence.
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Affiliation(s)
- Andrea Badillo
- Division of Colorectal and Pelvic Reconstruction, Children's National Medical Center, Washington, District of Columbia, United States
| | - Laura Tiusaba
- Division of Colorectal and Pelvic Reconstruction, Children's National Medical Center, Washington, District of Columbia, United States
| | - Shimon Eric Jacobs
- Division of Colorectal and Pelvic Reconstruction, Children's National Medical Center, Washington, District of Columbia, United States
| | - Tamador Al-Shamaileh
- Department of General Surgery, Faculty of Medicine, Mutah University, Karak, Jordan
| | - Christina Feng
- Division of Colorectal and Pelvic Reconstruction, Children's National Medical Center, Washington, District of Columbia, United States
| | - Teresa Lynn Russell
- Division of Colorectal and Pelvic Reconstruction, Children's National Medical Center, Washington, District of Columbia, United States
| | - Elizaveta Bokova
- Division of Colorectal and Pelvic Reconstruction, Children's National Medical Center, Washington, District of Columbia, United States
| | - Anthony Sandler
- Division of Colorectal and Pelvic Reconstruction, Children's National Medical Center, Washington, District of Columbia, United States
| | - Marc A Levitt
- Division of Colorectal and Pelvic Reconstruction, Children's National Medical Center, Washington, District of Columbia, United States
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3
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Kennedy U, Daugherty M, Frischer J, DeFoor W, Strine AC, Reddy PP, Sheldon C, Minevich E, VanderBrink BA. Reoperative Anorectal Procedures in Patients with Anorectal Malformations - Is Bladder Function Affected? J Pediatr Surg 2023; 58:1910-1915. [PMID: 37217362 DOI: 10.1016/j.jpedsurg.2023.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 04/04/2023] [Accepted: 04/19/2023] [Indexed: 05/24/2023]
Abstract
BACKGROUND Anorectal malformations (ARM) are associated with neurogenic bladder. The traditional surgical ARM repair is a posterior sagittal anorectoplasty (PSARP), which is believed to have a minimal effect on bladder dynamics. However, little is known about the effects of reoperative PSARP (rPSARP) on bladder function. We hypothesized that a high rate of bladder dysfunction existed in this cohort. METHODS We performed a retrospective review of ARM patients undergoing rPSARP at a single institution from 2008 to 2015. Only patients with Urology follow-up were included in our analysis. Data was collected regarding original level of ARM, coexisting spinal anomalies and indications for reoperation. We assessed urodynamic variables and bladder management (voiding, CIC or diverted) before and after rPSARP. RESULTS A total of 172 patients were identified, of which 85 met inclusion criteria with a median follow-up of 23.9 months (IQR, 5.9-43.8 months). Thirty-six patients had spinal cord anomalies. Indications for rPSARP included mislocation (n = 42), posterior urethral diverticulum (PUD; n = 16), stricture (n = 19) and rectal prolapse (n = 8). Within 1 year following rPSARP, 11 patients (12.9%) had a negative change in bladder management, defined as need for beginning intermittent catheterization or undergoing urinary diversion, which increased to 16 patients (18.8%) at last follow-up. Postoperative bladder management changed in rPSARP patients with mislocation (p < 0.0001) and stricture (p 0.005) but not for rectal prolapse (p 0.143). CONCLUSIONS Patients who undergo rPSARP warrant especially close attention for bladder dysfunction as we observed a negative postoperative change in bladder management in 18.8% of our series. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Uchenna Kennedy
- University Children's Hospital of Zurich, University of Zurich, Steinwiesstrasse 75, 8032, Zurich, Switzerland
| | - Michael Daugherty
- Cincinnati Children's Hospital Medical Center, Division of Pediatric Urology, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Jason Frischer
- Cincinnati Children's Hospital Medical Center, Department of Pediatric Surgery, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - William DeFoor
- Cincinnati Children's Hospital Medical Center, Division of Pediatric Urology, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Andrew C Strine
- Cincinnati Children's Hospital Medical Center, Division of Pediatric Urology, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Pramod P Reddy
- Cincinnati Children's Hospital Medical Center, Division of Pediatric Urology, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Curtis Sheldon
- Cincinnati Children's Hospital Medical Center, Division of Pediatric Urology, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Eugene Minevich
- Cincinnati Children's Hospital Medical Center, Division of Pediatric Urology, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Brian A VanderBrink
- Cincinnati Children's Hospital Medical Center, Division of Pediatric Urology, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA.
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4
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Bokova E, Svetanoff WJ, Lopez JJ, Levitt MA, Rentea RM. State of the Art Bowel Management for Pediatric Colorectal Problems: Anorectal Malformations. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10050846. [PMID: 37238394 DOI: 10.3390/children10050846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/28/2023] [Accepted: 05/04/2023] [Indexed: 05/28/2023]
Abstract
Up to 79% of patients with anorectal malformations (ARMs) experience constipation and/or soiling after a primary posterior sagittal anoplasty (PSARP) and are referred to a bowel management program. We aim to report the recent updates in evaluating and managing these patients as part of the manuscript series on the current bowel management protocols for patients with colorectal diseases (ARMs, Hirschsprung disease, functional constipation, and spinal anomalies). The unique anatomic features of ARM patients, such as maldeveloped sphincter complex, impaired anal sensation, and associated spine and sacrum anomalies, indicate their bowel management plan. The evaluation includes an examination under anesthesia and a contrast study to exclude anatomic causes of poor bowel function. The potential for bowel control is discussed with the families based on the ARM index calculated from the quality of the spine and sacrum. The bowel management options include laxatives, rectal enemas, transanal irrigations, and antegrade continence enemas. In ARM patients, stool softeners should be avoided as they can worsen soiling.
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Affiliation(s)
- Elizaveta Bokova
- Comprehensive Colorectal Center, Department of Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA
| | - Wendy Jo Svetanoff
- Comprehensive Colorectal Center, Department of Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA
| | - Joseph J Lopez
- Comprehensive Colorectal Center, Department of Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA
| | - Marc A Levitt
- Division of Colorectal and Pelvic Reconstruction, Children's National Medical Center, Washington, DC 20001, USA
| | - Rebecca M Rentea
- Comprehensive Colorectal Center, Department of Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA
- Department of Surgery, University of Missouri-Kansas City, Kansas City, MO 64108, USA
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5
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Badillo A, Tiusaba L, Jacobs SE, Al-Shamaileh T, Feng C, Russell TL, Bokova E, Sandler A, Levitt MA. Sparing the Perineal Body: A Modification of the Posterior Sagittal Anorectoplasty for Anorectal Malformations with Rectovestibular Fistulae. Eur J Pediatr Surg 2023. [PMID: 36929124 DOI: 10.1055/s-0043-1760838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
BACKGROUND The posterior sagittal anorectoplasty (PSARP) used to repair an anorectal malformation (ARM) with a rectovestibular fistula involves incising the perineal body skin and the sphincter muscles and a posterior sagittal incision to the coccyx. Perineal body dehiscence is the most common and morbid complication post-PSARP which can have a negative impact on future bowel control. With consideration of all the other approaches described to repair this anomaly, we developed a perineal body sparing modification of the standard PSARP technique. METHODS Four patients with ARM with a rectovestibular fistula were repaired with a perineal body sparing modified PSARP at a single institution between 2020 and 2021. The incision used was limited, involving only the length of the anal sphincter, with no incision anterior or posterior to the planned anoplasty. Dissection of the distal rectum and fistula was performed without cutting the perineal body. Once the distal rectum was mobilized off the posterior vaginal wall and out of the vestibule, the perineal body muscles, where the fistula had been, were reinforced and an anoplasty was then performed. RESULTS Operative time was the same as for a standard PSARP. There were no intraoperative or postoperative complications. No postoperative dilations were performed. All patients healed well with an excellent cosmetic result. All are too young to assess for bowel control. CONCLUSION We present a new technique, a modification of the traditional PSARP for rectovestibular fistula, which spares the perineal body. This approach could eliminate the potential complication of perineal body dehiscence.
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Affiliation(s)
- Andrea Badillo
- Division of Colorectal and Pelvic Reconstruction, Children's National Medical Center, Washington, District of Columbia, United States
| | - Laura Tiusaba
- Division of Colorectal and Pelvic Reconstruction, Children's National Medical Center, Washington, District of Columbia, United States
| | - Shimon Eric Jacobs
- Division of Colorectal and Pelvic Reconstruction, Children's National Medical Center, Washington, District of Columbia, United States
| | - Tamador Al-Shamaileh
- Department of General Surgery, Faculty of Medicine, Mutah University, Karak, Jordan
| | - Christina Feng
- Division of Colorectal and Pelvic Reconstruction, Children's National Medical Center, Washington, District of Columbia, United States
| | - Teresa Lynn Russell
- Division of Colorectal and Pelvic Reconstruction, Children's National Medical Center, Washington, District of Columbia, United States
| | - Elizaveta Bokova
- Division of Colorectal and Pelvic Reconstruction, Children's National Medical Center, Washington, District of Columbia, United States
| | - Anthony Sandler
- Division of Colorectal and Pelvic Reconstruction, Children's National Medical Center, Washington, District of Columbia, United States
| | - Marc A Levitt
- Division of Colorectal and Pelvic Reconstruction, Children's National Medical Center, Washington, District of Columbia, United States
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6
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Liaqat N, Wood R, Fuchs M. Hypospadias and anorectal malformation: A difficult combination. J Pediatr Surg 2023; 58:228-230. [PMID: 36379749 DOI: 10.1016/j.jpedsurg.2022.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 10/11/2022] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Anorectal malformation (ARM) and hypospadias are both multifactorial and complex diseases, and they present in a spectrum of varieties. However, these pathologies have not been studied jointly in literature. The objective of this study was to look for the association between subtypes of ARM and types of hypospadias. MATERIAL AND METHODS We conducted a retrospective review of the male patients with ARM, who had been treated at our center. We retrieved information regarding demographic details, ARM sub-type, hypospadias type, and urological problems after the chart review. All data were analyzed using SPSS version 26. RESULTS A total of 408 patients were included, and 87 patients (20%) had hypospadias and ARM. There was no significant association between the severity of ARM and the severity of hypospadias. Most of the patients having proximal hypospadias belonged to the "simple" ARM group (15/22). The frequency of Vesicoureteric reflux (VUR), hydronephrosis, atrophic kidney, and at least one urological abnormality was significantly higher in patients having hypospadias and showed the strongest relationships with hypospadias. Holding the presence of hypospadias constant, ARM severity was noticeably correlated with all outcomes except solitary kidney. CONCLUSION We conclude that hypospadias is a common entity among patients with ARM. These patients, having dual pathologies, are at significantly higher risk to develop other urological problems. And they should be considered a special group of patients and need close surveillance for urological issues. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Naeem Liaqat
- Pediatric Surgeon, PAF Hospital, Islamabad, Pakistan.
| | - Richard Wood
- Chief, Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, OH, United States
| | - Molly Fuchs
- Consultant, Department of Urology, Nationwide Children's Hospital, Columbus, Ohio, United States
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7
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Patient driven change: Is collaborative care the future of medicine? Lessons learned from the care of children with colorectal problems. J Pediatr Surg 2023; 58:189-197. [PMID: 36418202 DOI: 10.1016/j.jpedsurg.2022.10.023] [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: 09/28/2022] [Accepted: 10/11/2022] [Indexed: 11/21/2022]
Abstract
A basic premise in the care of complex patients is that experience, increased volume of cases, and an integrated, multi-disciplinary approach yields improved outcomes. Is this true using the example of the care of children with colorectal and pelvic reconstructive needs? This review gives a brief historical context on how care for this patient group evolved, delineates the key elements to create a collaborative care model, and describes multiple advances that have been developed, based on the model, which have improved patient care and quality of life. LEVEL OF EVIDENCE: Review.
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8
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Evans-Barns HME, Tien MY, Trajanovska M, Safe M, Hutson JM, Dinning PG, King SK. Post-operative colonic manometry in children with anorectal malformations: A systematic review. Neurogastroenterol Motil 2022; 34:e14415. [PMID: 35699343 PMCID: PMC10078517 DOI: 10.1111/nmo.14415] [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: 11/28/2021] [Revised: 03/07/2022] [Accepted: 04/20/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Children with anorectal malformations may experience constipation and fecal incontinence following repair. The contribution of altered anorectal function to these persistent symptoms is relatively intuitive; however, colonic motility in this cohort is less well understood. Manometry may be used to directly assess colonic motility. PURPOSE The purpose of this systematic review was to synthesize the available evidence regarding post-operative colonic motility in children with anorectal malformations and evaluate the reported equipment and protocols used to perform colonic manometry in this cohort. This systematic review was conducted in compliance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). We conducted a systematic review of four databases: Embase, MEDLINE, PubMed, and the Cochrane Library (1st January 1985-22nd July 2021). Studies reporting colonic manometry performed in children following anorectal malformation repair were assessed for eligibility. Data were extracted independently by two authors. Four studies were eligible for inclusion. Of the combined total cohort of 151 children, post-operative colonic manometry was conducted in 35. Insufficient reporting of medical characteristics, bowel function, and manometric outcomes restricted comparison between studies, and limited clinical applicability. No results from high-resolution colonic manometry were identified. Despite the prevalence of post-operative bowel dysfunction in children with repaired anorectal malformations, this systematic review highlighted the markedly limited evidence regarding post-operative colonic motility. This cohort may benefit from assessment with high-resolution techniques; however, future work must emphasize adherence to standardized manometry protocols, and include robust reporting of surgical characteristics, bowel function, and manometric outcomes.
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Affiliation(s)
- Hannah M E Evans-Barns
- Department of Paediatric Surgery, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Surgical Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Melissa Y Tien
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Misel Trajanovska
- Department of Paediatric Surgery, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Surgical Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Mark Safe
- Department of Gastroenterology and Clinical Nutrition, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - John M Hutson
- Surgical Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Department of Urology, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Phil G Dinning
- Department of Surgery, College of Medicine and Public Health, The Flinders University and Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Sebastian K King
- Department of Paediatric Surgery, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Surgical Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
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9
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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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10
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Li L, Zhou Y, Ming A, Xu H, Li Q, Li X, Huang G, Tian Y, Wu Y, Tai J, Xie X, Tam PKH, Gu Q, Diao M. Pattern of anatomic disorder and surgical management of anorectal prolapse in anorectal malformation. Pediatr Surg Int 2022; 38:993-1004. [PMID: 35596086 DOI: 10.1007/s00383-022-05141-y] [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] [Accepted: 04/19/2022] [Indexed: 10/18/2022]
Abstract
AIM Due to the paucity of data and controversy regarding the etiology and surgical approach for managing anorectal prolapse (ARP) after anorectoplasty, we sought to investigate the underlying anatomic disorder and the surgical outcome in managing this challenging complication. METHODS We performed a retrospective study on 83 patients with ARP related to anorectal malformations (ARM). Logistic regression analyses were performed to detect the risk factors for the ARP severity. Surgical procedures were stratified according to identified anatomical abnormalities and surgical outcomes were analyzed. RESULTS 50 patients (62.7%) had high-type ARM. The original anorectoplasty had a higher rate of ARP in laparoscopic-assisted anorectoplasty (n = 49, 59.0%) versus posterior sagittal anorectoplasty (n = 11, 13.3%). ARP was associated with rectal fat hyperplasia (67.5%), dilated muscular tunnel (79.5%), longitudinal muscle (LM) discontinuity (16.9%), rectal dilation (22.9%), mislocated anus (7.2%), and excessive mobile mesorectum (3.6%). Based on the ARP severity, the patients were divided into a severe group (Group 1, n = 38) and a moderate group (Group 2, n = 45). Binary logistic regression analysis showed that hyperplasia rectal fat (OR 4.55, 95% CI 1.16-17.84), rectal dilation (OR 4.21, 95% CI 1.05-16.94), and high-type ARM (OR 2.90, 95% CI 1.14-7.39) were independent risk factors for the development of severe ARP. Complications after stratified surgical repair included wound infection in six patients (7.2%), anal stenosis in one patient (1.2%), and ARP recurrence in two patients (2.4%). Twenty-six patients without colostomy before prolapse repair were followed up for 2 to 12 years. All the patients maintained voluntary bowel movements. Following ARP repair, there was an overall higher rate of no soiling or grade 1 soiling (88.5 vs. 65.4%), but 3 of 12 patients with grade 2 constipation were upgraded to grade 3. CONCLUSION Our study shows that ARM-related anorectal prolapse is associated with excessive rectum, hyperplasia of rectal fat, mobile mesorectum, loose muscular tunnel, LM discontinuity, and anal mislocation. Surgical repair with techniques stratified according to the patients' underlying risk factors is effective to prevent recurrence and improve the soiling continence.
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Affiliation(s)
- Long Li
- Department of Pediatric Surgery, Capital Institute of Pediatrics, No.2 Yabao Road, Chaoyang District, Beijing, 100020, China. .,Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China. .,Research Unit of Minimally Invasive Pediatric Surgery On Diagnosis and Treatment (2021RU015), Chinese Academy of Medical Sciences, Beijing, China.
| | - Yan Zhou
- Department of Pediatric Surgery, Capital Institute of Pediatrics, No.2 Yabao Road, Chaoyang District, Beijing, 100020, China.,Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Anxiao Ming
- Department of Pediatric Surgery, Capital Institute of Pediatrics, No.2 Yabao Road, Chaoyang District, Beijing, 100020, China
| | - Hang Xu
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Qi Li
- Department of Pediatric Surgery, Capital Institute of Pediatrics, No.2 Yabao Road, Chaoyang District, Beijing, 100020, China
| | - Xu Li
- Department of Pediatric Surgery, Capital Institute of Pediatrics, No.2 Yabao Road, Chaoyang District, Beijing, 100020, China
| | - Guimin Huang
- Child Health Big Data Research Center, Capital Institute of Pediatrics, Beijing, China
| | - Yu Tian
- Department of Pediatric Surgery, Capital Institute of Pediatrics, No.2 Yabao Road, Chaoyang District, Beijing, 100020, China
| | - Yurui Wu
- Department of Thoracic Surgery, Capital Institute of Pediatrics, Beijing, China
| | - Jun Tai
- Department of Otorhinolaryngology, Capital Institute of Pediatrics, No.2 Yabao Road, Chaoyang District, Beijing, 100020, China
| | - Xianghui Xie
- Department of Pediatric Surgery, Capital Institute of Pediatrics, No.2 Yabao Road, Chaoyang District, Beijing, 100020, China
| | - Paul K H Tam
- Faculty of Medicine, Macau University of Science and Technology, Macau, China.,Department of Surgery, University of Hong Kong, Hong Kong, China
| | - Qinglong Gu
- Department of Otorhinolaryngology, Capital Institute of Pediatrics, No.2 Yabao Road, Chaoyang District, Beijing, 100020, China.
| | - Mei Diao
- Department of Pediatric Surgery, Capital Institute of Pediatrics, No.2 Yabao Road, Chaoyang District, Beijing, 100020, China.
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11
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AbouZeid AA, Mohammad SA. Anatomical derangements after failed PSARP: correlating MRI and operative findings. ANNALS OF PEDIATRIC SURGERY 2021. [DOI: 10.1186/s43159-021-00094-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Redo surgery for anorectal anomalies (ARA) may be considered a special category of reconstructive surgery with less predictable outcomes. In this report, we studied anatomical derangements in a group of boys following a previously complicated PSARP procedure, in addition to the effect of reoperation on rectifying this distorted anatomy.
Results
The study included 27 boys who were re-operated after a previous complicated PSARP. Included cases were divided into two groups: group A (14 cases) was referred before colostomy closure with an obviously complicated primary operation, and group B (13 cases) was referred with delayed complications after colostomy closure.
Pelvic MRI examinations were performed before reoperation in 19 cases. In nine of these cases, a repeat MRI examination was performed at follow-up after reoperation to study the effect of redo surgery on rectifying the distorted anatomy.
Abnormal wide anorectal angle and wide pelvic hiatus were common anatomical derangements after a previously complicated PSARP. An important goal of reoperation was reconstruction of the levator ani behind the anorectum trying to create a more acute anorectal angle and a narrower pelvic hiatus. The success of this corrective step was evaluated by MRI comparing pre- and postoperative measurements that showed a favourable decrease in the values of anorectal angle and hiatal/PC ratio. Improvement of faecal continence was documented after reoperation in 8 out of 10 cases in group B.
Conclusion
A wide pelvic hiatus was a frequently encountered postsurgical complication after failed PSARP that has most probably resulted from poor reconstruction of the pelvic floor at time of the primary repair. Re-approximation of the split halves of levator ani in the midline behind the anorectum at reoperation can help to correct the distorted internal anatomy and improve bowel control in these cases.
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12
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Wood RJ, Halleran DR, Ahmad H, Vilanova-Sanchez A, Rentea RM, Stallings P, Ganesh N, Gasior A, Levitt MA. Reply to letter to the editor: "Assessing the benefit of reoperations in patients who suffer from fecal incontinence after repair of their anorectal malformation". J Pediatr Surg 2021; 56:1256-1257. [PMID: 33558072 DOI: 10.1016/j.jpedsurg.2021.01.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 01/26/2021] [Indexed: 10/22/2022]
Affiliation(s)
- Richard J Wood
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, 700 Children's Drive, Nationwide Children's Hospital, Columbus, OH 43205, United States.
| | - Devin R Halleran
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, 700 Children's Drive, Nationwide Children's Hospital, Columbus, OH 43205, United States
| | - Hira Ahmad
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, 700 Children's Drive, Nationwide Children's Hospital, Columbus, OH 43205, United States
| | - Alejandra Vilanova-Sanchez
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, 700 Children's Drive, Nationwide Children's Hospital, Columbus, OH 43205, United States
| | - Rebecca M Rentea
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, 700 Children's Drive, Nationwide Children's Hospital, Columbus, OH 43205, United States
| | - Patrick Stallings
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, 700 Children's Drive, Nationwide Children's Hospital, Columbus, OH 43205, United States
| | - Nisha Ganesh
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, 700 Children's Drive, Nationwide Children's Hospital, Columbus, OH 43205, United States
| | - Alessandra Gasior
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, 700 Children's Drive, Nationwide Children's Hospital, Columbus, OH 43205, United States
| | - Marc A Levitt
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, 700 Children's Drive, Nationwide Children's Hospital, Columbus, OH 43205, United States
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13
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Lane VA, Calisto J, deBlaauw I, Calkins CM, Samuk I, Avansino JR. Assessing the previously repaired patient with an anorectal malformation who is not doing well. Semin Pediatr Surg 2020; 29:150995. [PMID: 33288142 DOI: 10.1016/j.sempedsurg.2020.150995] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
In this review, the care of children with a previously repaired anorectal malformation is explored. We know that the surgical care of children with anorectal malformations is complex; however, despite an increased understanding of the congenital anomaly and significant technical advances in the operative repair, many of these children continue to have poor functional outcomes. In this article we focus on the common surgical complications, discuss typical presentations, consider appropriate investigations, and review the risks and benefits of revisional surgery in those patients that are 'not doing well' following their primary reconstruction.
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Affiliation(s)
- Victoria A Lane
- Department of Paediatric Surgery, Great North Children's Hospital, Newcastle-Upon-Tyne, UK.
| | - Juan Calisto
- Colorectal Center, Nicklaus Children's Hospital, Miami, FL, USA
| | - Ivo deBlaauw
- Radboud University Medical Center, Nijmegen, the Netherlands
| | - Casey M Calkins
- The Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Inbal Samuk
- Department of Pediatric Surgery, Schneider Children's Medical Center of Israel, Petach Tikva, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Jeffrey R Avansino
- Reconstructive Pelvic Medicine Program, Seattle Children's Hospital, Seattle, WA, USA; Department of Surgery, University of Washington, USA
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14
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Rentea RM, Badillo AT, Hosie S, Sutcliffe JR, Dickie B. Lasting impact on children with an anorectal malformations with proper surgical preparation, respect for anatomic principles, and precise surgical management. Semin Pediatr Surg 2020; 29:150986. [PMID: 33288132 DOI: 10.1016/j.sempedsurg.2020.150986] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Optimal outcomes in the management of children with Anorectal Malformation (ARM) require careful surgical preparation and detailed understanding of the anatomic principles and operative setup. A clear understanding of operative anatomy and surgical principals guides decision making. Adherence to the principles of ARM repair, as well as the application of operative and imaging adjuncts, will yield the safest and most successful approach to ARM. In this review, we detail the surgical preparation, anatomic principles, and surgical management issues unique to ARM.
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Affiliation(s)
- Rebecca M Rentea
- Comprehensive Colorectal Center, Department of Surgery, Children's Mercy-Kansas City, Kansas City, MO 64108, USA.
| | - Andrea T Badillo
- Divisions of Pediatric Surgery and Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, DC, USA
| | - Stuart Hosie
- Department of Pediatric Surgery, Stadtisches Kinikum Munchen GmBH, Munich, Germany
| | - Jonathan R Sutcliffe
- Department of Pediatric Surgery, Leeds General Infirmary, Leeds LS1 3EX, United Kingdom
| | - Belinda Dickie
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
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