Variation in Practice Surrounding Antegrade Colonic Enema Channel Placement

PURPOSE

Antegrade colonic enemas (ACE) can be an effective management option for defecation disorders and improve quality of life. Best practice regarding channel placement is unclear and variation may exist around preferred initial type of channel, age at placement, and underlying diagnoses. We aimed to describe practice patterns and patient characteristics around ACE channel placement.

METHODS

We conducted a multicenter retrospective study of children with an ACE channel cared for at sites participating in the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC) from 2017 to 2022. Kruskal-Wallis test was utilized to test the age at surgery by site with significance level of 0.05.

RESULTS

500 patients with ACE channel were included. 293 (58.6%) patients had their ACE procedure at a PCPLC center. The median age at surgery was 7.6 [IQR 5.3-11.0] years for the overall cohort and 8.1 [IQR 5.3-11.5] years for placement at PCPLC centers. For PCPLC centers, median age at placement varied significantly across centers (p = 0.009). 371 (74.2%) patients received Malone appendicostomy, 116 (23.2%) received cecostomy, and 13 (2.6%) received Neo-Malone appendicostomy. Median age of patients by channel type was 7.7 [IQR 5.3-11.0], 7.5 [IQR 5.7-11.0], and 9.8 [IQR 4.2-11.6] years, respectively. The most common indication for cecostomy was idiopathic/refractory constipation (52.6%), whereas anorectal malformation was the most common indication for Malone (47.2%) and Neo-Malone (61.5%). Among ACE channels placed at PCPLC centers, there was variation across institutions in preferred initial channel type. The 4 highest volume centers favored Malone appendicostomy over cecostomy.

CONCLUSION

There is variation in practice of ACE channel placement. At specialty pediatric colorectal centers, age at time of placement and type of channel placed varied across institutions. Further work is needed to better characterize diagnosis- and age-focused patient centered outcomes to clarify recommendations for our patients who benefit from these procedures.

TYPE OF STUDY

Retrospective comparative study.

LEVEL OF EVIDENCE

Level III.

Influence of Initial Treatment Strategy on Outcomes for Children With Rectal Prolapse

OBJECTIVE

Pediatric rectal prolapse is a common and often self-limited condition with multiple management options. Selecting the optimal approach requires personalization and remains a challenge for pediatricians and pediatric surgeons.

METHODS

A single-center retrospective review of 67 children with rectal prolapse undergoing surgical evaluation between 2010 and 2021. Patients with anorectal malformations, Hirschsprung disease, inflammatory bowel disease, and cystic fibrosis were excluded. We used multivariable logistic regression to compare medical management, sclerotherapy, and surgical correction (rectopexy or transanal resection) as initial treatment strategies, with a primary endpoint of prolapse resolution.

RESULTS

Younger patients (<5 years) were more likely to be initially treated with medical management alone (P < 0.001). Patients with a psychiatric diagnosis were more likely to be offered either sclerotherapy or surgery upfront (P = 0.009). The resolution rate with surgery as initial management was 79% (n = 11/14). The resolution rate with sclerotherapy as initial management was 54% (n = 13/24), with 33% (n = 8/24) resolving with sclerotherapy alone and 21% (n = 5/24) resolving after a subsequent surgical procedure (P = 0.011). Patients who underwent initial surgical management had an adjusted odds ratio of 8.0 (95% CI: 1.1-59.1; P = 0.042) for resolution of prolapse compared to patients who underwent sclerotherapy initially. Markers of severity (bleeding, need for manual reduction) were not associated with initial therapy offered (P = 0.064).

CONCLUSIONS

Surgical intervention (sclerotherapy, rectopexy, transanal resection) resolved rectal prolapse in most children (63%). Surgery as an initial management approach had a significantly higher success rate than sclerotherapy, even after controlling for severity of disease, psychiatric diagnosis, need for manual reduction, and age.

Long-Term Functional Outcomes at 1-Year After Hospital Discharge in Critically Ill Neonates With Congenital Diaphragmatic Hernia

OBJECTIVES

Congenital diaphragmatic hernia (CDH) is a birth defect associated with long-term morbidity. Our objective was to examine longitudinal change in Functional Status Scale (FSS) after hospital discharge in CDH survivors.

DESIGN

Single-center retrospective cohort study.

SETTING

Center for comprehensive CDH management at a quaternary, free-standing children's hospital.

PATIENTS

Infants with Bochdalek CDH were admitted to the ICU between January 2009 and December 2019 and survived until hospital discharge.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

One hundred forty-two infants (58% male, mean birth weight 3.08 kg, 80% left-sided defects) met inclusion criteria. Relevant clinical data were extracted from the medical record to calculate FSS (primary outcome) at hospital discharge and three subsequent outpatient follow-up time points. The median (interquartile range [IQR]) FSS score at hospital discharge was 8.0 (7.0-9.0); 39 patients (27.5%) had at least moderate impairment (FSS ≥ 9). Median (IQR) FSS at 0- to 6-month (n = 141), 6- to 12-month (n = 141), and over 12-month (n = 140) follow-up visits were 7.0 (7.0-8.0), 7.0 (6.0-8.0), and 6.0 (6.0-7.0), respectively. Twenty-one patients (15%) had at least moderate impairment at over 12-month follow-up; median composite FSS scores in the over 12-month time point decreased by 2.0 points from hospital discharge. Median feeding domain scores improved by 1.0 (1.0-2.0), whereas other domain scores remained without impairment. Multivariable analysis demonstrated right-sided, C- or D-size defects, extracorporeal membrane oxygenation use, cardiopulmonary resuscitation, and chromosomal anomalies were associated with impairment.

CONCLUSIONS

The majority of CDH survivors at our center had mild functional status impairment (FSS ≤ 8) at discharge and 1-year follow-up; however, nearly 15% of patients had moderate impairment during this time period. The feeding domain had the highest level of functional impairment. We observed unchanged or improving functional status longitudinally over 1-year follow-up after hospital discharge. Longitudinal outcomes will guide interdisciplinary management strategies in CDH survivors.

Hirschsprung-associated inflammatory bowel disease: A multicenter study from the APSA Hirschsprung disease interest group

BACKGROUND/PURPOSE

A small number of Hirschsprung disease (HD) patients develop inflammatory bowel disease (IBD)-like symptoms after pullthrough surgery. The etiology and pathophysiology of Hirschsprung-associated IBD (HD-IBD) remains unknown. This study aims to further characterize HD-IBD, to identify potential risk factors and to evaluate response to treatment in a large group of patients.

METHODS

Retrospective study of patients diagnosed with IBD after pullthrough surgery between 2000 and 2021 at 17 institutions. Data regarding clinical presentation and course of HD and IBD were reviewed. Effectiveness of medical therapy for IBD was recorded using a Likert scale.

RESULTS

There were 55 patients (78% male). 50% (n = 28) had long segment disease. Hirschsprung-associated enterocolitis (HAEC) was reported in 68% (n = 36). Ten patients (18%) had Trisomy 21. IBD was diagnosed after age 5 in 63% (n = 34). IBD presentation consisted of colonic or small bowel inflammation resembling IBD in 69% (n = 38), unexplained or persistent fistula in 18% (n = 10) and unexplained HAEC >5 years old or unresponsive to standard treatment in 13% (n = 7). Biological agents were the most effective (80%) medications. A third of patients required a surgical procedure for IBD.

CONCLUSION

More than half of the patients were diagnosed with HD-IBD after 5 years old. Long segment disease, HAEC after pull through operation and trisomy 21 may represent risk factors for this condition. Investigation for possible IBD should be considered in children with unexplained fistulae, HAEC beyond the age of 5 or unresponsive to standard therapy, and symptoms suggestive of IBD. Biological agents were the most effective medical treatment.

LEVEL OF EVIDENCE

Level 4.

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)

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.

Lasting impact on children with an anorectal malformations with proper surgical preparation, respect for anatomic principles, and precise surgical management

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.

Measure twice and cut once: Comparing endoscopy and 3D cloacagram for the common channel and urethral measurements in patients with cloacal malformations

INTRODUCTION

Precise and accurate measurement of the common channel and urethra is a critical determinant prior to the repair of cloacal malformations. Endoscopy and 3D reconstruction cloacagram are two common modalities utilized to help plan the surgical approach, however the consistency between these methods is unknown.

METHODS

Common channel and urethral lengths obtained by endoscopy and 3D cloacagram of cloaca patients at six pediatric colorectal centers were compared. Data are given as mean (range).

RESULTS

72 patients were included in the study. Common channel measurements determined by 3D cloacagram and endoscopy were equal in 7 cases (10%). Endoscopic measurements of the common channel were longer than 3D cloacagram in 20 (28%) cases and shorter in the remaining 44 (62%) cases. The absolute difference between measurements of the common channel was 7.2 mm (0-2.4 cm). Urethral measurements by both modalities were equal in 8 cases (12%). Endoscopic measurement of the urethra was longer than that by 3D cloacagram in 20 (31%) patients and shorter in 37 (57%) of cases. The absolute difference between measurements of the urethra was 5.1 mm (0-2.0 cm). The reconstruction (e.g. TUM or urogenital separation) that would be performed according to measurements determined by 3D cloacagram and endoscopic measurements differed in 13/62 (21%) patients with each structure identified and common channel measurements of >1 cm.

CONCLUSION

Significant variation exists in the measurements of the common channel and urethra in patients with cloacal malformations as determined by endoscopy and 3D cloacagram. This variation should be considered as these measurements influence the decision to perform either a TUM or urogenital separation. Based on these findings, 3D cloacagram should be performed in all patients prior to cloaca repair to prevent mischaracterization of the malformation.

LEVEL OF EVIDENCE

Level IV.

Telemedicine in pediatric surgery

IMPORTANCE

Telemedicine is an emerging strategy for healthcare delivery that has the potential to expand access, optimize efficiency, minimize cost, and enhance patient satisfaction.

OBJECTIVE

To review the current spectrum, potential strategies, and implementation process of telemedicine in pediatric surgery.

DESIGN

Review and opinion design.

SETTING

n/a.

PARTICIPANTS

n/a. MAIN OUTCOMES AND MEASURES: n/a.

RESULTS

n/a.

CONCLUSIONS AND RELEVANCE

Telemedicine is an emerging approach with the potential to facilitate efficient, cost-effective delivery of pediatric surgical services.

BRIEF ABSTRACT

Telemedicine is an emerging strategy for healthcare delivery that has the potential to expand access, optimize efficiency, minimize cost, and enhance patient satisfaction. The objectives of this review are to explore common terms in telemedicine, provide an overview of current legislative and billing guidelines, review the current state of telemedicine in surgery and pediatric surgery, and provide basic themes for successful implementation of a pediatric surgical telemedicine program.

TYPE OF STUDY

Review.

LEVEL OF EVIDENCE

Level V.

Damaged anal canal as a cause of fecal incontinence after surgical repair for Hirschsprung disease - a preventable and under-reported complication

INTRODUCTION

Fecal incontinence after the surgical repair of Hirschsprung disease is a potentially preventable complication that carries a negative impact on patient's quality of life.

METHODS

Patients that were previously operated for Hirschsprung disease and presented to our bowel management clinic with the complaint of fecal incontinence were retrospectively reviewed. All patients underwent a rectal examination under anesthesia looking for anatomic explanations for their incontinence.

RESULTS

One hundred three patients were identified. 54 patients had a damaged anal canal. 22 patients also had a patulous anus. The operative reports mentioned the pectinate line in 32 patients, in 12 it was not mentioned, and in 10 patients the operative report was not available. All patients with a damaged anal canal suffered from true fecal incontinence; 45 of them are on daily enemas (41 are clean and 4 are still having "accidents"), 7 are not doing bowel management due to noncompliance and 2 patients have a permanent ileostomy. 49 patients did not have a damaged anal canal, 25 of those responded to changes in diet and medication and are having voluntary bowel movements.

CONCLUSION

Fecal incontinence may occur after an operation for Hirschsprung disease. When the anal canal is damaged, incontinence is always present, severe, and probably permanent. The preservation of the anal canal may avoid this complication.

Treatment of adults with unrecognized or inadequately repaired anorectal malformations: 17 cases of rectovestibular and rectoperineal fistulas

STUDY OBJECTIVE

To analyze all cases of congenital rectovestibular and rectoperineal fistulas diagnosed and treated later in life, and to describe presenting complaints, treatment, and outcome.

DESIGN

Retrospective cohort study.

SETTING

Pediatric surgery departments of 3 major referral centers in the US and Europe.

PARTICIPANTS

Seventeen women with untreated or inadequately treated rectovestibular or rectoperineal fistulas.

INTERVENTIONS

Analyses of all eligible patients: charts were analyzed for the classification of the malformation, main complaints, continence, sexual function, indications for surgery, associated anomalies, surgical procedure, complications, and outcome.

MAIN OUTCOME MEASURES

Patients' complaints, continence, constipation, and sexual function.

RESULTS

Major complaints at time of diagnosis were fecal incontinence, and concerns for hygiene and cosmesis. All patients were repaired by a posterior sagittal approach. In all but 1 patient the complaints disappeared or improved after surgery.

CONCLUSIONS

Anorectal malformations in females are congenital malformations mostly seen and treated in early childhood. If unrepaired or inadequately repaired the patient, when reaching adulthood, can suffer from significant morbidity. Surgical treatment is similar as in childhood and has an excellent clinical outcome.

Foregut duplication cyst associated with esophageal atresia and tracheoesophageal fistula: a case report and literature review

A case of esophageal atresia associated with a foregut duplication cyst is reported and the literature reviewed. This is the first documented occurrence in conjunction with Down syndrome and the second case where both anomalies were treated at the initial surgery.

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

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

Lung nodules in pediatric oncology patients: a prediction rule for when to biopsy

PURPOSE

The purpose of the study was to develop a prediction rule regarding the factors that most accurately predict the diagnosis of a malignancy in a lung nodule in the pediatric oncology patient.

METHODS

A retrospective review of pediatric oncology patients that underwent lung nodule resection between 1998 and 2007 was performed. Multivariable logistic regression was used to create a prediction rule.

RESULTS

Fifty pediatric oncology patients underwent 21 thoracotomies and 48 thoracoscopies to resect discrete lung nodules seen on computed tomographic scans during workup for metastasis or routine surveillance. The mean nodule size was 10.43 ± 7.08 mm. The most significant predictors of malignancy in a nodule were peripheral location (odds ratio [OR], 9.1); size between 5 and 10 mm (OR, 2.78); location within the right lower lobe (OR, 2.43); and patients with osteosarcoma (OR, 10.8), Ewing sarcoma (OR, 3.05), or hepatocellular carcinoma (OR, 2.38).

CONCLUSIONS

Lesions that are between 5 and 10 mm in size and peripherally located in patients with osteosarcoma, Ewing sarcoma, or hepatocellular carcinoma are most likely to be malignant. Use of a prediction rule can help guide clinical practice by determining which patients should undergo surgical resection of lung nodules and which patients may be closely observed with continued radiologic studies.

Evaluation and treatment of the patient with Hirschsprung disease who is not doing well after a pull-through procedure

Ideally, after operative management of Hirschsprung disease, a child should thrive, avoid recurrent episodes of abdominal distention and enterocolitis, and be fecally continent. However, there is a small group of patients that do not do well after their pull-through procedure. The purpose of this article is to describe our algorithm for the work-up and management of the post pull-through patient with Hirschsprung disease who is not doing well. These children can be categorized into 2 distinct groups: (1) those who are soiling, and (2) those who suffer from distention and enterocolitis. Both of these patient types can be systematically treated with a combination of bowel management, dietary changes, and laxatives, and, potentially, a redo operation, with the goal of having a clean, and happy child.

Spectrum of hepatic hemangiomas: management and outcome

PURPOSE

Infants with multiple cutaneous hemangiomas often present with hepatic hemangiomas. They can follow a benign clinical course or require complex management. We reviewed our experience in the management of hepatic hemangiomas.

METHODS

We performed a retrospective review of patients (1996-2007) with hepatic hemangiomas treated in our institution.

RESULTS

Twenty-six patients were diagnosed with hepatic hemangiomas as follows: 8 focal, 12 multiple, and 6 diffuse lesions. Nineteen (73%) patients had associated cutaneous hemangiomas. Sixteen patients had multiple and 3 patients had single cutaneous hemangiomas. All patients with multiple or diffuse liver lesions were screened for heart failure and hypothyroidism. Congestive heart failure developed in 4 patients, 3/4 of these patients had diffuse lesions. Two patients required thyroid replacement because of elevated thyroid-stimulating hormone. Because of progression of disease, 9 patients required steroid treatment. Two patients were treated with vincristine and 3 patients received alpha-interferon because of poor response to steroid treatment. Two patients went on to surgical resection for failed response to medical management and worsening heart failure (left lobectomy, liver transplant). Both patients had uncomplicated postoperative courses. Five patients had a previously undescribed constellation of rapidly involuting cutaneous hemangiomas (gone by 3 months, glut-1-negative) with associated liver lesions also resolving at a faster pace (mean resolution of cutaneous hemangiomas, 1.9 vs 7.9 months; P = .001; liver, 5.8 vs 25.3 months; P = .004). All patients in our series survived.

CONCLUSION

Patients with multiple cutaneous hemangiomas should be screened for hepatic lesions. Patients with diffuse or multifocal liver hemangiomas should be screened for congestive heart failure and hypothyroidism. A subgroup of rapidly involuting cutaneous hemangiomas have a significantly shorter time for involution of hepatic lesions. The status of cutaneous lesions can be used as indicators for the liver hemangiomas.

Patients who reoffend while on warrants of the Lieutenant-Governor

Occasionally, psychiatric patients detained in institutions against their will or residing in the community under legal restraints elope and commit serious offenses. The authors looked at the frequency with which this occurred with patients on warrants of the Lieutenant-Governor in Ontario. Using the files of the Ontario Lieutenant-Governor's Board of Review, they examined the records and isolated such recorded incidents over a 16 year period. In spite of the limitations identified by the authors, their findings indicate a lower than expected occurrence. As well, they point to the risk management implications of certain diagnostic groups being treated in a less than secure setting.