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Beati F, D'Angelo T, Iacusso C, Iacobelli BD, Scorletti F, Valfré L, Pellegrino C, Bagolan P, Conforti A, Fusaro F. The use of postoperative calibrations in Hirschsprung disease: a practice to reconsider? Pediatr Surg Int 2024; 40:176. [PMID: 38967682 DOI: 10.1007/s00383-024-05761-6] [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: 06/25/2024] [Indexed: 07/06/2024]
Abstract
PURPOSE Daily postoperative anal dilations after endorectal pull-through for Hirschsprung disease (HD) are still considered a common practice. We analyzed the potential risks of this procedure and its effectiveness compared to a new internal protocol. METHODS All infants (< 6 months of age) who underwent transanal endorectal pull-through between January 2021 and January 2023 were prospectively enrolled in a new postoperative protocol group without daily anal dilations (Group A) and compared (1:2 fashion) to those previously treated by postoperative anal dilations (Group B). Patients were matched for age and affected colonic tract. Patients with associated syndromes, extended total intestinal aganglionosis, and presence of enterostomy were excluded. Outcomes considered were: anastomotic complications (stenosis, disruption/leakage), incidence of enterocolitis, and constipation. RESULTS Eleven patients were included in group A and compared to 22 matched patients (group B). There were no significant differences in the occurrence of anastomotic complications between the two groups. We found a lower incidence of enterocolitis and constipation among group A (p = 0.03 and p = 0.02, respectively). CONCLUSION A non-dilation strategy after endorectal pull-through could be a feasible alternative and does not significantly increase the risk of postoperative anastomotic complications. Moreover, some preliminary advantages such as lower enterocolitis rate and constipation should be further investigated.
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Affiliation(s)
- Federico Beati
- Neonatal Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Piazza S Onofrio 4, 00165, Rome, Italy
| | - Tommaso D'Angelo
- Neonatal Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Piazza S Onofrio 4, 00165, Rome, Italy
| | - Chiara Iacusso
- Neonatal Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Piazza S Onofrio 4, 00165, Rome, Italy
| | - Barbara Daniela Iacobelli
- Neonatal Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Piazza S Onofrio 4, 00165, Rome, Italy
| | - Federico Scorletti
- Neonatal Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Piazza S Onofrio 4, 00165, Rome, Italy
| | - Laura Valfré
- Neonatal Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Piazza S Onofrio 4, 00165, Rome, Italy
| | - Chiara Pellegrino
- Division of Neuro-Urology, Bambino Gesu' Children's Hospital, IRCCS, Piazza di Sant'Onofrio 4, 00165, Rome, RM, Italy
| | - Pietro Bagolan
- Area of Fetal, Neonatal and Cardiological Sciences Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
- Department of Systems Medicine, University of Rome "Tor Vergata", 00165, Rome, Italy
| | - Andrea Conforti
- Neonatal Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Piazza S Onofrio 4, 00165, Rome, Italy
| | - Fabio Fusaro
- Neonatal Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Piazza S Onofrio 4, 00165, Rome, Italy.
- Intestinal Failure Surgical Rehabilitation Unit, Bambino Gesù Children's Hospital, IRCCS, Piazza S Onofrio 4, 00165, Rome, Italy.
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Knaus ME, Westgarth-Taylor C, Gasior AC, Halaweish I, Thomas JL, Srinivas S, Levitt MA, Wood RJ. A Modification of the Anoplasty Technique during a Posterior Sagittal Anorectoplasty and Anorectal Vaginal Urethroplasty Closure: The Para-U-Stitch to Prevent Wound Dehiscence. Eur J Pediatr Surg 2024; 34:222-227. [PMID: 36693415 DOI: 10.1055/a-2019-0030] [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: 01/26/2023]
Abstract
OBJECTIVE Wound dehiscence after posterior sagittal anorectoplasty (PSARP) or anorectal vaginal urethroplasty (PSARVUP) for anorectal malformation (ARM) is a morbid complication. We present a novel anoplasty technique employing para-U-stitches along the anterior and posterior portions of the anoplasty, which helps buttress the midline U-stitch and evert the rectal mucosa. We hypothesized that, in addition to standardized pre- and postoperative protocols, this technique would lower rates of wound dehiscence. MATERIALS AND METHODS A retrospective review of patievnts who underwent primary PSARP or PSARVUP with the para-U-stitch technique from 2015 to 2021 was performed. Wound dehiscence was defined as wound disruption requiring operative intervention within 30 days of the index operation. Superficial wound separations were excluded. Descriptive statistics were calculated. The final cohort included 232 patients. RESULTS Rectoperineal fistula (28.9%) was the most common ARM subtype. PSARP was performed in 75% and PSARVUP in 25%. The majority were reconstructed with a stoma in place (63.4%). Wound dehiscence requiring operative intervention occurred in four patients, for an overall dehiscence rate of 1.7%. The dehiscence rate was lower in PSARPs compared with PSARVUPs (0.6 vs. 5.2%) and lower for reconstruction without a stoma compared with a stoma (1.2 vs. 2.0%). There were additional six patients (2.6%) with superficial wound infections managed conservatively. CONCLUSION We present the para-U-stitch anoplasty technique, which is an adjunct to the standard anoplasty during PSARP and PSARVUP. In conjunction with standardized pre- and postoperative protocols, this technique can help decrease rates of wound dehiscence in this patient population.
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Affiliation(s)
- Maria E Knaus
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, Ohio, United States
| | | | - Alessandra C Gasior
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, Ohio, United States
| | - Ihab Halaweish
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, Ohio, United States
| | - Jessica L Thomas
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, Ohio, United States
| | - Shruthi Srinivas
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, Ohio, United States
| | - Marc A Levitt
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, Ohio, United States
| | - Richard J Wood
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, Ohio, United States
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Wehrli LA, Ariefdjohan M, Ketzer J, Matkins K, De la Torre L, Bischoff A, Judd-Glossy L. "Take It One Dilation at a Time": Caregiver Perspectives of Postoperative Anal Dilations in Pediatric Patients with Colorectal Conditions. Behav Sci (Basel) 2024; 14:379. [PMID: 38785870 PMCID: PMC11118838 DOI: 10.3390/bs14050379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 04/25/2024] [Accepted: 04/25/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Postoperative anal dilations (PAD) are the standard of care for patients after a posterior sagittal anorectoplasty (PSARP) for anorectal malformation (ARM) or a transanal pull-through (TP) procedure for Hirschsprung disease (HD). This study assessed the psychosocial impact of PAD among caregivers of children with ARM or HD, which may inform postoperative care strategies. METHODS Caregivers of patients with ARM and HD who underwent PSARP or TP within five years participated in the online survey. Questions included demographics, patient and caregiver experiences with PAD, and baseline psychosocial functioning. Quantitative results were reported descriptively, while qualitative responses were summarized as major themes. RESULTS The survey indicated a response rate of 26% caregivers, with most being female (91%) and biological mothers (85%). Patients were mostly male (65%), born with ARM (74%), and were five months old on average when PAD began. Caregivers reported that during PAD, children experienced distress (56%), pain (44%), and fear (41%), while a third noted no negative reactions. Over time, their child's ability to cope with PAD got easier (38%) or stayed the same (41%). Caregivers reported worry/anxiety (88%), guilt (71%), stress (62%), and frustration (35%), noting that additional coping strategies to manage the emotional and logistical challenges of daily PAD would be helpful. CONCLUSION Although PAD is necessary, it can be highly stressful for the patients and their caregivers. Key findings emphasized the need for additional coping strategies and highlighted the importance of integrating psychosocial support into the postoperative care regimen.
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Affiliation(s)
- Lea A. Wehrli
- International Center for Colorectal and Urogenital Care, Children’s Hospital Colorado, Aurora, CO 80045, USA; (L.A.W.); (J.K.); (K.M.); (L.D.l.T.); (A.B.)
| | - Merlin Ariefdjohan
- Child and Adolescent Mental Health Division, Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA;
| | - Jill Ketzer
- International Center for Colorectal and Urogenital Care, Children’s Hospital Colorado, Aurora, CO 80045, USA; (L.A.W.); (J.K.); (K.M.); (L.D.l.T.); (A.B.)
| | - Kristina Matkins
- International Center for Colorectal and Urogenital Care, Children’s Hospital Colorado, Aurora, CO 80045, USA; (L.A.W.); (J.K.); (K.M.); (L.D.l.T.); (A.B.)
| | - Luis De la Torre
- International Center for Colorectal and Urogenital Care, Children’s Hospital Colorado, Aurora, CO 80045, USA; (L.A.W.); (J.K.); (K.M.); (L.D.l.T.); (A.B.)
| | - Andrea Bischoff
- International Center for Colorectal and Urogenital Care, Children’s Hospital Colorado, Aurora, CO 80045, USA; (L.A.W.); (J.K.); (K.M.); (L.D.l.T.); (A.B.)
| | - Laura Judd-Glossy
- International Center for Colorectal and Urogenital Care, Children’s Hospital Colorado, Aurora, CO 80045, USA; (L.A.W.); (J.K.); (K.M.); (L.D.l.T.); (A.B.)
- Child and Adolescent Mental Health Division, Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA;
- Pediatric Mental Health Institute, Children’s Hospital Colorado, Aurora, CO 80045, USA
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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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5
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Qureshi MA, Liaqat N, Iqbal A, Ashkanani A, Kumar S, Ali AR, Abdul SAH, Taqi E. Five Years' Single-center Experience of a Modified Approach to Divided Sigmoid Colostomy for Anorectal Malformation. J Pediatr Surg 2023; 58:2327-2331. [PMID: 37652845 DOI: 10.1016/j.jpedsurg.2023.08.003] [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: 03/30/2023] [Revised: 06/21/2023] [Accepted: 08/03/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND In patients with anorectal malformation (ARM), a divided descending colostomy is associated with high complication rates, including wound infection, dehiscence, and prolapse, and it places a significant burden on caregivers. To decrease the chances of such complications, we modified our approach for colostomy fashioning by keeping an intact skin bridge between the colostomy and mucous fistula. The objective was to compare the rate of complications among patients diagnosed with ARM who underwent a modified divided descending colostomy and classical descending colostomy. METHODS We included all the patients diagnosed with ARM who underwent a divided colostomy with modified (group A) or classical technique (group B) in the last 5 years. The type of approach used to fashion the stoma was based on the surgeon's preference than on patients' selection criteria. All patients were followed and monitored for postoperative complications. SPSS version 26 was used to analyze the data. RESULTS A total of 62 patients with ARM underwent the colostomy creation; 27 in group A and 35 in group B. Males were more in both groups and other demographic variables were comparable. The most common associated anomalies were cardiac (58%). The mean duration of surgery was 72.2 ± 18.26 min in group A while 91.25 ± 21.43 min in group B (P = 0.000). The mean hospital stay was 4.28 ± 3.63 days in group A while 7.97 ± 6.12 days in group B (P = 0.007). The overall complication rate was 14.8% in group A and 34.2% in group B (P = 0.082). CONCLUSION The modified approach to fashioning a divided colostomy is easily reproducible and carries a low risk of postoperative complications. LEVEL OF EVIDENCE IV.
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6
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Maraschin FG, Adella FJ, Nagraj S. A scoping review of the post-discharge care needs of babies requiring surgery in the first year of life. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002424. [PMID: 37992047 PMCID: PMC10664918 DOI: 10.1371/journal.pgph.0002424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 11/01/2023] [Indexed: 11/24/2023]
Abstract
Congenital anomalies are among the leading causes of under-5 mortality, predominantly impacting low- and middle-income countries (LMICs). A particularly vulnerable group are babies with congenital disorders requiring surgery in their first year. Addressing this is crucial to meet SDG-3, necessitating targeted efforts. Post-discharge, these infants have various care needs provided by caregivers, yet literature on these needs is scant. Our scoping review aimed to identify the complex care needs of babies post-surgery for critical congenital cardiac conditions and non-cardiac conditions. Employing the Joanna Briggs Institute's methodological framework for scoping reviews we searched Pubmed, EMBASE, CINAHL, PsychINFO, and Web of Science databases. Search terms included i) specific congenital conditions (informed by the literature and surgeons in the field), ii) post-discharge care, and iii) newborns/infants. English papers published between 2002-2022 were included. Findings were summarised using a narrative synthesis. Searches yielded a total of 10,278 papers, with 40 meeting inclusion criteria. 80% of studies were conducted in High-Income Countries (HICs). Complex care needs were shared between cardiac and non-cardiac congenital conditions. Major themes identified included 1. Monitoring, 2. Feeding, and 3. Specific care needs. Sub-themes included monitoring (oxygen, weight, oral intake), additional supervision, general feeding, assistive feeding, condition-specific practices e.g., stoma care, and general care. The post-discharge period poses a challenge for caregivers of babies requiring surgery within the first year of life. This is particularly the case for caregivers in LMICs where access to surgical care is challenging and imposes a financial burden. Parents need to be prepared to manage feeding, monitoring, and specific care needs for their infants before hospital discharge and require subsequent support in the community. Despite the burden of congenital anomalies occurring in LMICs, most of the literature is HIC-based. More research of this nature is essential to guide families caring for their infants post-surgical care.
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Affiliation(s)
- Francesca Giulia Maraschin
- Health Systems Collaborative, Centre for Global Health Research, The Nuffield Department of Medicine, The University of Oxford, Oxford, United Kingdom
| | - Fidelis Jacklyn Adella
- Health Systems Collaborative, Centre for Global Health Research, The Nuffield Department of Medicine, The University of Oxford, Oxford, United Kingdom
| | - Shobhana Nagraj
- Health Systems Collaborative, Centre for Global Health Research, The Nuffield Department of Medicine, The University of Oxford, Oxford, United Kingdom
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7
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Karlsen RA, Hoel AT, Gjone H, Bjørnland K. Nurses' Experiences With Anal Dilatations in Babies With Anorectal Malformations - A Focus Group Interview Study. J Pediatr Surg 2023; 58:1929-1934. [PMID: 37246043 DOI: 10.1016/j.jpedsurg.2023.04.021] [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: 01/03/2023] [Revised: 04/12/2023] [Accepted: 04/25/2023] [Indexed: 05/30/2023]
Abstract
AIMS AND OBJECTIVES To explore nurses' experiences with anal dilatations in babies with anorectal malformations. BACKGROUND Most babies with anorectal malformations require repeated anal dilatations, either before and/or after reconstructive surgery. Anal dilatation is usually performed without sedation or pain medication. Nurses participate in anal dilatations by assisting doctors doing anal dilatation, doing anal dilatation themselves, and instructing parents how to do anal dilatations. No previous studies have explored how nurses experience being involved in anal dilatations. DESIGN Qualitative study design utilizing focus group interviews. The COREQ guidelines were applied. METHODS Nurses with either ≤2 or ≥10 years' working experience participated in two different focus group interviews. The focus group interviews were transcribed and analyzed with content analysis. RESULTS Twelve nurses, two males, participated. Three main themes emerged from the focus group interviews. The first main theme, "Anal dilatation causes distress", describes the nurses' worries about causing physical and/or psychological harm when doing anal dilatations. The second main theme, "Need for guidelines and training", contains nurses' recommendations for more theoretical training in addition to written guidelines on anal dilatations. The third main theme, "Collegial support is vital", describes nurses' needs and strategies for coping with difficult situations related to anal dilatations. CONCLUSIONS Anal dilatation causes distress in nurses, and collegial support is essential for coping. Guidelines and systematic training are recommended to improve current practice. LEVEL OF EVIDENCE VI.
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Affiliation(s)
| | - Anders Telle Hoel
- University of Oslo, Oslo, Norway; Department of Pediatric Surgery, Oslo University Hospital, Oslo, Norway
| | - Helene Gjone
- Department of Child and Adolescent Mental Health in Hospitals, Oslo University Hospital, Oslo, Norway
| | - Kristin Bjørnland
- University of Oslo, Oslo, Norway; Department of Pediatric Surgery, Oslo University Hospital, Oslo, Norway
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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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9
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Iantorno SE, Rollins MD, Austin K, Avansino JR, Badillo A, Calkins CM, Crady RC, Dickie BH, Durham MM, Frischer JS, Fuller MK, Grabowski JE, Ralls MW, Reeder RW, Rentea RM, Saadai P, Wood RJ, van Leeuwen KD, Short SS. Rectal Prolapse Following Repair of Anorectal Malformation: Incidence, Risk Factors, and Management. J Pediatr Surg 2023:S0022-3468(23)00252-X. [PMID: 37173214 DOI: 10.1016/j.jpedsurg.2023.04.010] [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: 04/17/2023] [Accepted: 04/18/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND The incidence and optimal management of rectal prolapse following repair of an anorectal malformation (ARM) has not been well-defined. METHODS A retrospective cohort study was performed utilizing data from the Pediatric Colorectal and Pelvic Learning Consortium registry. All children with a history of ARM repair were included. Our primary outcome was rectal prolapse. Secondary outcomes included operative management of prolapse and anoplasty stricture following operative management of prolapse. Univariate analyses were performed to identify patient factors associated with our primary and secondary outcomes. A multivariable logistic regression was developed to assess the association between laparoscopic ARM repair and rectal prolapse. RESULTS A total of 1140 patients met inclusion criteria; 163 (14.3%) developed rectal prolapse. On univariate analysis, prolapse was significantly associated with male sex, sacral abnormalities, ARM type, ARM complexity, and laparoscopic ARM repairs (p < 0.001). ARM types with the highest rates of prolapse included rectourethral-prostatic fistula (29.2%), rectovesical/bladder neck fistula (28.8%), and cloaca (25.0%). Of those who developed prolapse, 110 (67.5%) underwent operative management. Anoplasty strictures developed in 27 (24.5%) patients after prolapse repair. After controlling for ARM type and hospital, laparoscopic ARM repair was not significantly associated with prolapse (adjusted odds ratio (95% CI): 1.50 (0.84, 2.66), p = 0.17). CONCLUSION Rectal prolapse develops in a significant subset of patients following ARM repair. Risk factors for prolapse include male sex, complex ARM type, and sacral abnormalities. Further research investigating the indications for operative management of prolapse and operative techniques for prolapse repair are needed to define optimal treatment. TYPE OF STUDY Retrospective cohort study. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Stephanie E Iantorno
- Department of Surgery, Primary Children's Hospital, University of Utah, Salt Lake City, UT, USA.
| | - Michael D Rollins
- Department of Surgery, Primary Children's Hospital, University of Utah, Salt Lake City, UT, USA
| | - Kelly Austin
- Department of Surgery, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jeffrey R Avansino
- Department of Surgery, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Andrea Badillo
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, George Washington University, Washington, DC, USA
| | - Casey M Calkins
- Department of Surgery, Children's Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Rachel C Crady
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Belinda H Dickie
- Department of Surgery, Boston Children's Hospital, Harvard University, Boston, MA, USA
| | - Megan M Durham
- Emory + Children's Pediatric Institute, Atlanta, GA, USA
| | - Jason S Frischer
- Department of Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Megan K Fuller
- Department of Surgery, Boys Town Research Hospital-Children's of Omaha, University of Nebraska Medical Center, Boys Town, NE, USA
| | - Julia E Grabowski
- Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, IL, USA
| | - Matthew W Ralls
- Department of Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Rebecca M Rentea
- Department of Surgery, Children's Mercy Hospital, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Payam Saadai
- Department of Surgery, UC Davis Children's Hospital, University of California Davis, Davis, CA, USA
| | - Richard J Wood
- Department of Surgery, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Kathleen D van Leeuwen
- Department of Surgery, Phoenix Children's Hospital, University of Arizona, Phoenix, AZ, USA
| | - Scott S Short
- Department of Surgery, Primary Children's Hospital, University of Utah, Salt Lake City, UT, USA
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10
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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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Smith CA, Rollins MD, Durham MM, Rosen N, McCracken KA, Wood RJ. Speaking the same Language in multi-center research: Pediatric colorectal and Pelvic Learning Consortium (PCPLC) updated colorectal definitions for 2022. J Pediatr Surg 2023; 58:1020-1025. [PMID: 36737262 DOI: 10.1016/j.jpedsurg.2022.12.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 12/29/2022] [Indexed: 01/06/2023]
Affiliation(s)
- Caitlin A Smith
- Division of Pediatric General and Thoracic Surgery, Seattle Children's, University of Washington, Seattle, WA, USA.
| | - Michael D Rollins
- Department of Surgery, Primary Children's Hospital, University of Utah, Salt Lake City, UT, USA
| | - Megan M Durham
- Department of Surgery, Emory + Children's Pediatric Institute, Emory University School of Medicine, Atlanta, GA, USA
| | - Nelson Rosen
- Department of Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Kate A McCracken
- Department of Surgery, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Richard J Wood
- Department of Surgery, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
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12
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Stricture rate in patients after the repair of anorectal malformation following a standardized dilation protocol. Pediatr Surg Int 2022; 38:1717-1721. [PMID: 36107235 DOI: 10.1007/s00383-022-05219-7] [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: 09/03/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE The aim of this study was to determine and analyze the stricture rate in patients who underwent a PSARP or PSARVUP and followed a postoperative protocol of anal dilation (Fig. 1). METHODS A retrospective review of patients with anorectal malformation (ARM) who underwent a primary PSARP or PSARVUP from February 2016 to October 2021 was performed. Data collected included patients' demographics, type of ARM, age at the time of operation, postoperative complications, with emphasis on whether there were any strictures or any difficulties during dilations, and on follow-up. During the surgical repair, emphasis was placed on preserving the blood supply of the bowel and performing a tension-free bowel-to-skin anastomosis. RESULTS Eighty-four patients met the inclusion criteria. Forty-four patients were females: 21 recto-perineal fistula, 12 cloaca, 9 recto-vestibular fistula, one imperforate anus without fistula, and one patient had a complex anorectal and vaginal malformation with an anal stricture and a rectovaginal fistula. Forty patients were males: 14 recto-perineal fistula, 11 recto-urethral bulbar fistula, 6 recto-urethral prostatic fistula, 6 imperforate anus without fistula, and 2 bladder neck fistula. One patient had an anal stenosis with sacral agenesis, without a presacral mass. Patient ages ranged from 0 to 79 months (mean 7.5 months, median 5 months) at the time of surgery. Follow-up time ranged from 7 to 73 months (mean 38 months, median 35 months). No patient suffered of a postoperative anal stricture. Six patients suffered of a rectal prolapse that required a surgical repair. CONCLUSION Post-operative anal stricture after PSARP and PSARVUP can be avoided with proper surgical technique and postoperative care. Namely, by preserving adequate blood supply of the bowel and avoiding tension at the anoplasty, and by adhering to a structured protocol of anal dilations.
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13
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Jacobs SE, Tiusaba L, Bokova E, Al-Shamaileh T, Russell TL, Varda BK, Feng C, Badillo AT, Levitt MA. Where Is the Vagina? A Rectal Stricture after a Presumed Cloacal Repair Turns Out to be the Mobilized Vagina and a Missed High Rectovaginal Fistula. European J Pediatr Surg Rep 2022; 10:e145-e147. [PMID: 36225532 PMCID: PMC9550519 DOI: 10.1055/s-0042-1755538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 07/10/2022] [Indexed: 11/03/2022] Open
Abstract
We present a case of a rare complication in a 10-month-old female referred to our institution for an anal stricture after primary cloacal repair as an infant. Multimodal imaging, careful physical exam, and endoscopic evaluation revealed her vagina had been pulled through to the location of her anal sphincter muscle complex. We describe the correction of this problem, including identification of her rectum.
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Affiliation(s)
- Shimon E. Jacobs
- Department of Surgery, Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, District of Columbia, United States
| | - Laura Tiusaba
- Department of Surgery, Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, District of Columbia, United States
| | - Elizaveta Bokova
- Department of Surgery, Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, District of Columbia, United States
| | - Tamador Al-Shamaileh
- Department of General Surgery, Division of Pediatric Surgery, King Hussain Cancer Center, Amman, Jordan
| | - Teresa L. Russell
- Department of Urology, Children's National Hospital, Washington, District of Columbia, United States,Address for correspondence Marc A. Levitt, MD Department of Surgery, Division of Colorectal and Pelvic Reconstruction, Children's National HospitalWashington, DC 20010United States
| | - Briony K. Varda
- Department of Urology, Children's National Hospital, Washington, District of Columbia, United States
| | - Christina Feng
- Department of Surgery, Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, District of Columbia, United States
| | - Andrea T. Badillo
- Department of Surgery, Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, District of Columbia, United States
| | - Marc A. Levitt
- Department of Surgery, Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, District of Columbia, United States
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Abd Elwahab SM, Zaidan H, Antao B, Mortell A. Response to: Are routine postoperative dilations necessary after primary posterior sagittal anorectoplasty? A randomized controlled trial. J Pediatr Surg 2022; 57:241. [PMID: 35361483 DOI: 10.1016/j.jpedsurg.2022.02.020] [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: 02/14/2022] [Accepted: 02/14/2022] [Indexed: 10/19/2022]
Affiliation(s)
- Sami Medani Abd Elwahab
- Department of General and Colorectal Paediatric Surgery, Children's Health Ireland (CHI) at Crumlin, Dublin 12, Ireland.
| | - Hind Zaidan
- Department of General and Colorectal Paediatric Surgery, Children's Health Ireland (CHI) at Crumlin, Dublin 12, Ireland
| | - Brice Antao
- Department of General and Colorectal Paediatric Surgery, Children's Health Ireland (CHI) at Crumlin, Dublin 12, Ireland
| | - Alan Mortell
- Department of General and Colorectal Paediatric Surgery, Children's Health Ireland (CHI) at Crumlin, Dublin 12, Ireland
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Short SS, Reeder RW, Lewis KE, Dickie B, Grabowski J, Sepuha T, Durham MM, Frischer J, Badillo A, Calkins CM, Rentea RM, Ralls M, Wood RJ, Fuller MK, van Leeuwen K, Avansino JR, Austin K, Rollins MD. The presence of a neurodiverse disorder is associated with increased use of antegrade enema therapy in children with severe constipation: A study from the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC). J Pediatr Surg 2022; 57:1676-1680. [PMID: 35597676 DOI: 10.1016/j.jpedsurg.2022.04.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 04/14/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Children with severe constipation and a neurodiverse disorder (Autism and/or developmental delay) represent a challenging bowel management group. Treatment outcomes with laxative or enema therapy remain limited and are often complicated by patient/caregiver compliance. We hypothesized that children with neurodiverse disorders and severe constipation would benefit from a bowel management program (BMP) that includes early use of antegrade enemas. MATERIALS AND METHODS Children requiring BMP in the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC) registry with diagnosis of constipation and/or constipation with pseudo-incontinence were reviewed. Those with Hirschsprung disease and/or Anorectal Malformation were excluded. BMP needs in patients with a neurodiverse diagnosis were compared to those without to evaluate differences in BMP's. RESULTS 372 patients requiring a BMP were identified. 95 patients (58 autism spectrum, 54 developmental delay) were neurodiverse, and 277 patients were not. Neurodiverse patients had a higher prevalence of enema therapy 62.1% (59/95) vs. 54.9% (152/273) and use of antegrade enema therapy 33.7% (32/95) vs. 21.2% (58/273), p = 0.126. Neurodiverse patients were older 37.9% (36/95) > 12 years vs. 23.1% (63/273), p = 0.001 and 47.6% (10/21) were changed from laxative to enema therapy over time. 80% (8/10) of those changed from laxatives to enemas used antegrade therapy. 67.3% (35/52) of neurodiverse patients followed over time were on enema therapy at the most recent visit with 80% (28/35) requiring antegrade therapy. CONCLUSION A large portion of patients with a neurodiverse disorder who fail laxative therapy use antegrade enemas to achieve effective bowel management. Early consideration of an antegrade conduit may simplify treatment in this group of children. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Scott S Short
- Primary Children's Hospital, 100 N. Mario Capecchi Drive, Suite 3800, Salt Lake City, UT 84108, USA.
| | | | | | | | | | | | | | | | | | | | | | - Matt Ralls
- C.S. Mott Children's Hospital/Univ. of Michigan, Ann Arbor, MI, USA
| | | | | | | | | | | | - Michael D Rollins
- Primary Children's Hospital, 100 N. Mario Capecchi Drive, Suite 3800, Salt Lake City, UT 84108, USA
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