Pernilla Stenström

Adolescents with anorectal malfromation: physical outcome, sexual health and quality of life

Abstract Background: The necessity of referring adolescents with anorectal malformation (ARM) from pediatric units to adult care is unclear. The issue requires knowledge about the health of the adolescent. Objective: To examine the physical outcome, sexual health and quality of life (QoL) in adolescents with ARM. Methods: At medical counseling, 24 adolescents with ARM, 15–21 years of age, answered questionnaires about physical outcome according to the Krickenbeck follow-up and QoL according to SF 36 and gastrointestinal quality of life (Giqli). Matched control groups were used; 15 adolescents participated in deep interviews about sexual health and body imaging. Results: Fecal soiling, constipation and gas incontinence were much higher for ARM patients compared with controls (p<0.05). QoL regarding large bowel function was lower for both genders compared with controls (p<0.05). Females scored lower in physically related QoL (p<0.05). Social and sexual adaption to the symptoms was obvious in the deep interviews. Conclusion: Adolescents with ARM have considerable intestinal symptoms, which influence QoL and require adaption in intimate situations. A referral to adult care seems to be important, and continuous cooperation between the pediatric surgeon and adult care is suggested.

Serial transverse enteroplasty to facilitate enteral autonomy in selected children with short bowel syndrome.

Serial transverse enteroplasty (STEP) was first described in 2003 as a method for lengthening and tapering of the bowel in short bowel syndrome. The aim of this multicentre study was to review the outcome of a Swedish cohort of children who underwent STEP.

Appendicitis in Children: Evaluation of the Pediatric Appendicitis Score in Younger and Older Children

Background. This study aimed to evaluate Pediatric Appendicitis Score (PAS), diagnostic delay, and factors responsible for possible late diagnosis in children <4 years compared with older children who were operated on for suspected appendicitis. Method. 122 children, between 1 and 14 years, operated on with appendectomy for suspected appendicitis, were retrospectively analyzed. The cohort was divided into two age groups: ≥4 years (n = 102) and <4 years (n = 20). Results. The mean PAS was lower among the younger compared with the older patients (5.3 and 6.6, resp.; P = 0.005), despite the fact that younger children had more severe appendicitis (75.0% and 33.3%, resp.; P = 0.001). PAS had low sensitivity in both groups, with a significantly lower sensitivity among the younger patients. Parent and doctor delay were confirmed in children <4 years of age with appendicitis. PAS did not aid in patients with doctor delay. Parameters in patient history, symptoms, and abdominal examination were more diffuse in younger children. Conclusion. PAS should be used with caution when examining children younger than 4 years of age. Diffuse symptoms in younger children with acute appendicitis lead to delay and to later diagnosis and more complicated appendicitis.

Prolonged Use of Proton Pump Inhibitors as Stricture Prophylaxis in Infants with Reconstructed Esophageal Atresia.

Introduction Proton pump inhibitors (PPIs) are used as prophylaxis, guarding against anastomotic stricture (AS) in the aftermath of reconstructed esophageal atresia (EA). The incidence of stricture formation was studied in this setting, comparing outcomes of 3‐ and 12‐month PPI prophylactic regimens. Patients and Methods Patient characteristics (gestational age, birth weight, prevalence of chromosomal aberrations, and other malformations), as well as rates of survival, AS formation, and required balloon dilation, were recorded in the following therapeutic subsets: (1) all infants undergoing primary surgical anastomosis for EA in years 2010–2014 and given postoperative PPI prophylaxis for 12 months and (2) all infants similarly treated for EA in years 2001–2009 but given postoperative PPI prophylaxis for 3 months only. Duration of follow‐up was 1 year in each group. Results Patient characteristics and survival rates in 12‐month (n = 33) and in 3‐month (n = 30) treatment groups did not differ significantly. The prevalence of AS was 42%/43% in each group (12 months, 14/33; 3 months, 13/30; p = 1). Median number of dilations required was 3 (range, 1–9) per patient in each group (p = 0.69). Median age at initial dilation was 163 days and 63 days in 12‐ and 3‐month groups, respectively (p = 0.04). Conclusion Development of AS in the first year after reconstruction of EA was not reduced by prolonged PPI prophylaxis (12 vs. 3 months), but initial balloon dilation procedures were performed later in infants who were treated longer.

Bowel symptoms in children with anorectal malformation: A follow-up with a gender and age perspective.

BACKGROUND Gender specific outcome for children with anorectal malformations (ARM) is rarely reported although it is important for medical care and in parent counseling. PURPOSE To assess bowel function according to the Krickenbeck system in relation to ARM-subtype, gender and age. METHOD All children born with ARM in 1998-2008 and referred to two centers in two different countries were followed up. The bowel function in 50 girls and 71 boys, median age 8 years, was analyzed. RESULTS Among those with a perineal fistula, incontinence occurred in 42% of the females and in 10% of the males (p=0.005) whereas constipation occurred in 62% of the females and 35% of the males (p<0.001). No bowel symptoms differed between the females with perineal and vestibular fistulas (p>0.3 for every symptom). Sacral malformations were associated with incontinence only in males with rectourethral fistulas. Constipation among the males differed between the age groups: 58% versus 26% (p=0.013). Bowel symptoms did not change with age among the females. CONCLUSION Gender differences in outcome for children with ARM must be considered. Males with perineal fistulas had less incontinence and constipation than the females with perineal fistulas. The females with perineal and vestibular fistulas had similar outcomes.

Appendicostomy in preschool children with anorectal malformation: successful early bowel management with a high frequency of minor complications.

Aim. The aim of this study is to evaluate postoperatively bowel symptoms of antegrade colon enema through appendicostomies in preschool children with anorectal malformation (ARM). Method. 164 children with ARM operated on with posterior sagittal anorectal plasty were included. The malformations were classified according to Krickenbeck classification. Seventeen children in preschool age had an appendicostomy. The bowel symptoms according to the Krickenbeck follow-up were analysed pre- and postoperatively. All complications were registered. A questionnaire on the use of the appendicostomy was answered. Results. The median age (range) at the time of the appendicostomy was 4 (1–6) years. The observation time was 5 (0.5–14) years. The main indications for appendicostomy were incontinence and noncompliance to rectal enemas. Postoperatively there was a significant decrease in soiling and constipation (P < 0.001). The total complication rate was 43% with infections (29%), stenosis (12%), and retrograde leakage (0). The median time required for giving enema in the appendicostomy was 45 minutes (range: 15–120) once a day varying from 2 times/week to 3 times/day. And: complications are less frequent than in older children. Conclusion. Appendicostomy in preschool children with ARM is a way to achieve fecal cleanness before school start. The infection rate was high, but other complications are less frequent than in older children.

Wireless Esophageal pH Monitoring in Children.

INTRODUCTION A wireless BRAVO (Medtronic, Shoreview, MN) capsule for pH measurement in the diagnosis of gastroesophageal reflux disease (GERD) is intended to be less uncomfortable, and facilitates activity during the measuring period, compared to the usual method with a naso-esophageal catheter. The aim of this study was to report on our experience with the wireless system in children. A secondary aim was to see if there was any cut-off level for esophageal acid exposure causing esophagitis as verified by pathologic examination. MATERIALS AND METHODS A total of 62 wireless 24-hour pH measurements with the BRAVO capsule were carried out over a period of 2 years in 58 children with symptoms of GERD. The median age of the children was 8 +/- 4 years (range, 1-15). They underwent upper endoscopies and the placement of the capsule under general anesthesia. Correlations between endoscope findings and pathologic diagnosis were done. RESULTS In 10 children, the endoscopies showed esophagitis. The median percent time of pH <4 was 7.0 +/- 9.6% (range, 0-61). The DeMeester score was abnormally high in 33 children. Three children described dysphagia during the measuring time. In 3 patients, we experienced technical problems with the wireless system. Biopsies were taken in 49 children, of which 18 showed esophagitis, with no correlation to the 24-hour pH-measurement findings. CONCLUSIONS Ambulatory pH monitoring, using the wireless pH system, is feasible and was well tolerated by the children. No cut-off level for the acid exposure in correlation to pathologic diagnosis of esophagitis could be found. We recommend the use of the wireless pH-measurement system in children.

A Nordic multicenter survey of long-term bowel function after transanal endorectal pull-through in 200 patients with rectosigmoid Hirschsprung disease

OBJECTIVE Transanal endorectal pull-through (ERPT) is the most popular technique to treat Hirschsprung disease (HD). Still, there is limited knowledge on long-term bowel function. This cross-sectional, multicenter study assessed long-term bowel function in a large HD population and examined predictors of poor outcome. METHODS Patients older than four years or their parents filled out a validated questionnaire on bowel function. Clinical details were recorded retrospectively from medical records. RESULTS 73/200 (37%) patients reported absolutely no impaired bowel function, meaning no constipation, fecal accidents, stoma, appendicostomy or need for enemas. Seven (4%) had a stoma, and 33 (17%) used antegrade or rectal colonic enemas. Most disarrangements of fecal control and constipation were significantly less common in older age group, but abnormal defecation frequency and social problems remained unchanged. Syndromic patients (n=31) experienced frequent fecal accidents (46%) more often than nonsyndromic (14%, P<0.001). Having a syndrome (adjusted OR 5.6, 95% CI 2.1-15, P=0.001) or a complete transanal ERPT (adjusted OR 2.4, 95% CI 1.1-5.7, P=0.038) was significantly associated with poor outcome defined as having a stoma, an appendicostomy, daily fecal accidents or need of regular rectal wash outs. CONCLUSION A significant number of HD patients experience bowel problems many years after definite surgery. Fecal control was significantly better in older than younger HD patients, but some continued to have considerable bowel problems also as adults. A total transanal ERPT was associated with poorer outcome. Long-term follow-up of HD patients is warranted. Prognosis Study: Level II.

Outcomes of Various Interventions for First-Time Perianal Abscesses in Children

Introduction. In children treated surgically for first-time perianal abscesses, discovery and excision of concomitant fistulas may also be warranted. Aim. To evaluate children of varying age after incision and drainage of first-time perianal abscesses, examining recurrences rates with and without search for a fistula. Method. A retrospective review was conducted, analyzing children (ages 0–15 years) treated for first-time perianal abscesses at a tertiary pediatric surgical center, with a minimum follow-up of 6 months. Results. A total of 104 patients subjected to 112 treatments for first-time perianal abscesses were eligible. Surgical procedures constituted 84 (75%) of treatments, searching for fistulas in 49 (58%). In 34 (69%), fistulas were confirmed and treated. In the surgically treated subset, the recurrence rate was higher if no attempt was made to exclude a fistula (46%), as opposed to confirmed absence of a fistula (27%) or concurrent fistulotomy (9%; p = 0.02). Younger patients showed a higher recurrence rate (12/26; 46%), compared with older counterparts (11/58; 19%) (p = 0.002). Conclusion. In children surgically treated for first-time perianal abscess, recurrence rates appear to be lowered by locating and treating coexisting fistulas.

Development of Frequency of Stools over Time in Children with Hirschsprung Disease Posttransanal Endorectal One-Stage Pull-through.

BACKGROUND The transanal endorectal one-stage pull-through (TERPT) procedure in children with Hirschsprung disease (HD) is frequently used worldwide. To give the childrens families realistic expectations and to plan the medical care for the period after TERPT, the outcome is of great importance. AIM The aim of this article is to collect information on the number of stools passed daily after one-stage TERPT procedure for HD. Patients and METHODS A prospective follow-up study for collecting information on the outcome of planned TERPT from 2005 through 2012 was performed. A control group consisting of age and gender matched children was used. RESULTS The results show an initial high frequency of daily stools, median 12 stools/day (range, 3-30 stools/day), reaching an acceptable situation with median 4 stools/day (range, 0-10 stools/day) after 1 year. After 4 years, the number of stools did not differ significantly from healthy controls. CONCLUSION This study shows that it takes 4 years after TERPT before the number of stools becomes normalized. To compare the long-term outcome, it would be desirable to have uniform regular reports on the daily frequency of passed stools, incontinence, and constipation during the years after TERPT.