Extravert Surgical Resident Applicants Get Higher 360-Degree Evaluations From Coworkers.

INTRODUCTION: 360-degree evaluations are used as an assessment in order to identify strengths and weaknesses of, or as a continuous evaluation for, residents. The aim of this study was to investigate the relationship between personality and ratings on 360-degree evaluations among surgical residency applicants. A secondary aim was to describe the personality profile of applicants for a surgical residency position. METHODS: Doctors interviewed for a residency or locum position in general, urology, or pediatric surgery were included. Participants rated their personality on the Neutralized Big Five Inventory. A 360-degree assessment was conducted. Scores from two laparoscopic simulators were used as a measure of technical ability. Univariate analyses were used to assess the results. Student's t-test was used to compare personality and Pearson correlations between 360-degree assessment and personality. RESULTS: Fifty doctors participated: data were complete for 38. Personality profiles showed higher emotional stability, agreeableness, conscientiousness and openness ratings than the norm. Correlations revealed a significant relationship between extraversion and higher scores on the 360-degree assessments. Significant univariate correlations were found between extraversion and the 360-degree assessments, and two of the correlations held up after adjustment for multiple tests. No correlations with performance when using laparoscopic simulators were found. CONCLUSIONS: Applicants for surgical residency rated significantly higher than the norm in four personality domains. Extraversion correlated with overall higher scores in 360-degree assessments by coworkers. Higher scores were not related to objective measures of technical skill, highlighting the importance of using objective measures for assessment.

Systematic orientation of fresh rectal suction biopsies improves histopathological diagnostics in hirschsprung's disease - a method description and preliminary report.

BACKGROUND: Optimizing rectal suction biopsy (RSB) diagnostics in Hirschsprung's disease (HD) may shorten diagnostic time and prevent need for repeated biopsies. AIM: To explore whether systematic orientation of fresh RSB specimens increased biopsy quality, diagnostic times, diagnostic efficacy, and histopathologic workload, and to explore these outcome measures for aganglionic specimens. MATERIALS/METHODS: This was an observational case-control study conducted at a national referral center for HD on data collected from the local HD-diagnostic register. From 2019 each fresh RSB was oriented by the collector in a notch in a foam cushion, placed in a separate cassette, and sent in formalin for pathological analysis. Outcome measures of oriented RSB samples collected 2019-2021 were compared to those of non-oriented RSB samples collected 2015-2018. Staining/immunohistochemistry consisted of hematoxylin eosin, S-100 and calretinin. RESULTS: 78 children with 81 RSBs and 242 biopsy analyzes were included. The frequency of high-quality RSB specimens was higher in oriented: 40% (42/106) versus non-oriented 25% (34/136) (p = 0.018), the diagnostic turnaround time was shorter: 2 days (1-5) versus 3 days (2-8) (p = 0.015), and the number of additional sectioning/leveling/re-orientation per biopsy was lower: 7 (3-26) versus 16 (7-72) (p = 0.011). Specifically for aganglionic specimens, the frequency of high-quality biopsies was generally higher in oriented than in non-oriented RSB specimens: 47% (28/59) versus 14% (7/50) (p < 0.001); the diagnostic efficacy was higher 95% (19/20) versus 60% (9/15) (p = 0.027) and the diagnostic turnaround time shorter: 2 days (2-3) versus 3 days (2-8) (p = 0.036). CONCLUSIONS: Systematic orientation of fresh RSB specimens improves HD diagnostics. Improvement was consistent in aganglionic specimens.

Histopathological dimensions differ between aganglionic and ganglionic bowel wall in children with Hirschsprung's disease.

BACKGROUND: In the validation of new imaging technology for children with Hirschsprung's disease (HSCR), basic anatomical parameters of the bowel wall must be established specifically for this patient group. AIM: To explore differences in histoanatomical layers of bowel wall, comparing ganglionic and aganglionic bowel walls, and to examine if the bowel wall thickness is linked to patient weight. METHODS: This was an observational study of bowel specimens from children weighing 0-10 kg, operated on consecutively during 2018-2020. Ganglionic and aganglionic bowel walls were measured in digitalized microscopy images from 10 sites per trans-sectional specimen and compared regarding the thickness of their histoanatomical layers. RESULTS: Bowel walls were measured in 21 children. Full bowel wall thickness did not differ between aganglionic and ganglionic bowel (2.20 vs 2.04; p = 0.802) while weight at surgery correlated positively with both ganglionic and aganglionic bowel wall thickness (r = 0.688 and 0.849, respectively), and age at surgery with ganglionic bowel wall thickness (r = 0.517). In aganglionic segments, the muscularis externa layer was thicker compared to that in ganglionosis (0.45 vs 0.31 mm, p = 0.012) whereas the muscularis interna was thinner (0.45 vs 0.62 mm, p < 0.001). A diagnostic index was identified whereby a lower ratio of muscularis interna/externa thickness followed by a thinner muscularis interna differed between aganglionic and ganglionic bowel in all specimens. CONCLUSION: Thicknesses of the bowel wall's muscle layers differ between aganglionic and ganglionic bowel walls in children with HSCR. These findings support a diagnostic index that could be validated for transfer to instant diagnostic imaging techniques. LEVEL OF EVIDENCE: Diagnostic: 3.

Sex and age differences in lower urinary tract dysfunction in healthy children.

AIM: Information about healthy children's urinary tract symptoms is scarce but would be helpful in children with congenital urinary tract conditions. The aim of this study was to develop and evaluate a Lower Urinary Tract Dysfunction (LUTD) questionnaire. METHODS: A 15-item questionnaire based on definitions by the International Children's Continence Society (ICCS) about urinary tract function, was given to children 4-15 years old with no gastrointestinal or urinary tract conditions. The study was approved ethically. RESULTS: The response rate was 82% (311/377), 50% (n = 155) were girls. Children were of the age groups 3.5-7 years (n = 136), 8-12 years (n = 127), and 13-15 years (n = 48). More girls than boys reported urinary tract infections (20% vs 3%, p < 0.001), while prevalences of incontinence and enuresis were equivalent in both sexes. In the youngest age group, enuresis was the most frequently reported symptom (11%), then daytime incontinence (10%). The older children more frequently reported previous urinary tract infections (12% and 17% in respective groups) and daytime incontinence (9% and 6%, respectively). CONCLUSION: A LUTD questionnaire is developed and evaluated within this study. Daytime urinary incontinence is the overall most common lower urinary tract symptom and girls report infections more frequently than boys.

Different approaches to selection of surgical trainees in the European Union.

BACKGROUND: There is an increasing global interest in selection processes for candidates to surgical training. The aim of the present study is to compare selection processes to specialist surgeon training in the European Union (EU). A secondary goal is to provide guidance for evidence-based methods by a proposed minimum standard that would align countries within the EU. METHODS: Publications and grey literature describing selection strategies were sought. Correspondence with Union Européenne des Médecins Specialists (UEMS) Section of Surgery delegates was undertaken to solicit current information on national selection processes. Content analysis of 13 semi-structured interviews with experienced Swedish surgeons on the selection process. Two field trips to Ireland, a country with a centralized selection process were conducted. Based on collated information typical cases of selection in a centralized and decentralized setting, Ireland and Sweden, are described and compared. RESULTS: A multitude of methods for selection to surgical training programs were documented in the 27 investigated countries, ranging from locally run processes with unstructured interviews to national systems for selection of trainees with elaborate structured interviews, and non-technical and technical skills assessments. Associated with the difference between centralized and decentralized selection systems is whether surgical training is primarily governed by an employment or educational logic. Ireland had the most centralized and elaborate system, conducting a double selection process using evidence-based methods along an educational logic. On the opposite end of the scale Sweden has a decentralized, local selection process with a paucity of evidence-based methods, no national guidelines and operates along an employment logic, and Spain that rely solely on examination tests to rank candidates. CONCLUSION: The studied European countries all have different processes for selection of surgical trainees and the use of evidence-based methods for selection is variable despite similar educational systems. Selection in decentralized systems is currently often conducted non-transparent and subjectively. A suggested improvement towards an evidence-based framework for selection applicable in centralized and decentralized systems as well as educational and employer logics is suggested.

Performance and perception of haptic feedback in a laparoscopic 3D virtual reality simulator.

Background: The benefit of haptic feedback in laparoscopic virtual reality simulators (VRS) is ambiguous. A previous study found 32% faster acquisition of skills with the combination of 3 D and haptic feedback compared to 2 D only. This study aimed to validate perception and effect on performance of haptic feedback by experienced surgeons in the previously tested VRS. Material and methods: A randomized single blinded cross-over study with laparoscopists (>100 laparoscopic procedures) was conducted in a VRS with 3 D imaging. One group started with haptic feedback, and the other group without. After performing the suturing task with haptics either enabled or disabled, the groups crossed over to the opposite setting. Face validity was assessed through questionnaires. Metrics were obtained from the VRS. Results: The haptics for 'handling the needle', 'needle through tissue' and 'tying the knot' was scored as completely realistic by 3/22, 1/22 and 2/22 respectively. Comparing the metrics for maximum stretch damage between the groups revealed a significantly lower score when a group performed with haptics enabled p = .027 (haptic first group) and p < .001(haptic last group). Conclusion: Haptic feedback in VRS has limited fidelity according to the tested laparoscopic surgeons. In spite of this, significantly less stretch damage was caused with haptics enabled.

Faster acquisition of laparoscopic skills in virtual reality with haptic feedback and 3D vision.

BACKGROUND: The study investigated whether 3D vision and haptic feedback in combination in a virtual reality environment leads to more efficient learning of laparoscopic skills in novices. MATERIAL AND METHODS: Twenty novices were allocated to two groups. All completed a training course in the LapSim® virtual reality trainer consisting of four tasks: 'instrument navigation', 'grasping', 'fine dissection' and 'suturing'. The study group performed with haptic feedback and 3D vision and the control group without. Before and after the LapSim® course, the participants' metrics were recorded when tying a laparoscopic knot in the 2D video box trainer Simball® Box. RESULTS: The study group completed the training course in 146 (100-291) minutes compared to 215 (175-489) minutes in the control group (p = .002). The number of attempts to reach proficiency was significantly lower. The study group had significantly faster learning of skills in three out of four individual tasks; instrument navigation, grasping and suturing. Using the Simball® Box, no difference in laparoscopic knot tying after the LapSim® course was noted when comparing the groups. CONCLUSIONS: Laparoscopic training in virtual reality with 3D vision and haptic feedback made training more time efficient and did not negatively affect later video box-performance in 2D. [Formula: see text].

Simball Box for Laparoscopic Training With Advanced 4D Motion Analysis of Skills.

Background Laparoscopic skills training and evaluation outside the operating room is important for all surgeons learning new skills. To study feasibility, a video box trainer tracking 4-dimensional (4D) metrics was evaluated as a laparoscopic training tool. Method Simball Box is a video box trainer with authentic surgical instruments and camera with video recording, equipped with 4D motion analysis registered through trocars using machine vision technology. Residents attending a 3-day laparoscopy course were evaluated performing a laparoscopic surgical knot at start, middle, and end. Metrics were obtained. Feedback data were presented in reference to expert/tutorial performance. Results Ten right-handed residents were included. Median time (range) to finish the task was 359 (253-418), 129 (95-166), and 95 (52-156) seconds; 655%, 236%, and 174% of tutorial performance, with significance pre-/midcourse (P < .0001), pre-/postcourse (P < .0001), and mid-/postcourse (P = .0050). Combined median total instrument motion decreased pre-/midcourse from 1208 (845-1751) to 522 cm (411-810 cm); P = .042 to 405 cm (246-864 cm) postcourse; pre-/postcourse P < .0001; 673%, 291%, 225% of tutorial performance. Total angular distance in radians (range) was 150 (87-251), 65 (42-116), and 50 (33-136) with significance pre-/midcourse (P = .022) and pre-/postcourse (P = .0002). Right-handed average speed (cm/s) increased: 1.94 (1.11-2.27) pre-, 2.39 (1.56-2.83) mid-, 2.60 (1.67-3.19) postcourse with significance pre-/midcourse (P = .022) and pre-/postcourse (P = .002). Average acceleration (mm/s(2)) and motion smoothness (µm/s(3)) failed to show any difference. Conclusion For laparoscopic training and as a promising evaluation device, Simball Box obtained metrics mirroring progression well.

Massive Chylous Ascites in a 9-Year-Old Girl with Malrotation-A Case Report.

Malrotation leading to massive chylous ascites is rare. A 9-year-old girl was investigated for slowly increasing abdominal distension under a year. She had no vomiting, weight loss, or pain, but was bothered in social situations. Medical investigations, including ultrasound and computed tomography scans, revealed massive ascites. Laparocentesis yielded milk-colored fluid, confirmed as lymph through laboratory analysis. A complete blood count, liver function and hematologic parameters, chyle cytology, bacterial cultures, and polymerase chain reaction for tuberculosis were all within normal limits. She was referred to a tertiary center for vascular anomalies. A dynamic contrast-enhanced magnetic resonance lymphangiography showed normal lymphatic anatomy without leakage or flow obstruction. A whole-body magnetic resonance imaging revealed a central mesenteric rotation. She was referred to a tertiary center for pediatric surgery, where a laparoscopic Ladd's procedure was performed using a new 5 mm pediatric sealing device, along with an appendectomy using a 5 mm stapler. To derotate the bowel, fenestrations were created in compartments containing a substantial amount of chyle and ascites, resulting in the drainage of 2.4 L of fluid. She was discharged the day after surgery and has been in good health for 1 year. We present a video illustrating the Ladd's procedure steps in this patient.

Visuospatial ability is associated to 2D laparoscopic simulator performance amongst surgical residents.

Background: The technical skills of a surgeon influence surgical outcome. Testing technical aptitude at point of recruitment of surgical residents is only conducted in a few countries. This study investigated the impact of visuospatial ability (VSA), background factors, and manual dexterity on performance in two different laparoscopic surgical simulators amongst applicants and 1st year surgical residents. Method: Applicants from general surgery, pediatric surgery, and urology were included from seven hospitals in Sweden between 2017 and 2021. Some 73 applicants were invited and 50 completed. Participants filled out a background form, and were tested for manual dexterity, and visuospatial ability. Two laparoscopic simulators were used, one 2D video box trainer and one 3D Virtual Reality Simulator. Results: A significant association was found between the visuospatial ability test and 2D video box laparoscopic performance (95 % CI: 1.028-1.2, p-value <0.01). For every point on the visuospatial test the odds of accomplishing the task increased by 11 %. No association was found between VSA and performance in a laparoscopic VR simulator using 3D vision. No other background factors were associated with performance in the two laparoscopic simulators. Conclusion: Visuospatial ability in applicants to surgical residency positions is associated to performance in a 2D video box trainer. Knowledge of a resident's visuospatial ability can be used to tailor individualized laparoscopic training programs, and in the future might function as a selection tool concerning laparoscopic ability. Key message: Visuospatial ability differs greatly amongst applicants for surgical residency and is associated to laparoscopic simulator performance. Testing applicants' visuospatial ability could possibly be used to tailor individualized laparoscopic training programs or in the future as a selection tool concerning laparoscopic ability.

Design of a Pediatric Rectal Ultrasound Probe Intended for Ultra-High Frequency Ultrasound Diagnostics.

It has been shown that ultra-high frequency (UHF) ultrasound applied to the external bowel wall can delineate the histo-anatomic layers in detail and distinguish normal bowel from aganglionosis. This would potentially reduce or lessen the need for biopsies that are currently mandatory for the diagnosis of Hirschsprung's disease. However, to our knowledge, no suitable rectal probes for such a use are on the market. The aim was to define the specifications of an UHF transrectal ultrasound probe (50 MHz center frequency) suitable for use in infants. Probe requirements according to patient anatomy, clinicians' requests, and biomedical engineering UHF prerequisites were collected within an expert group. Suitable probes on the market and in clinical use were reviewed. The requirements were transferred into the sketching of potential UHF ultrasound transrectal probes followed by their 3D prototype printing. Two prototypes were created and tested by five pediatric surgeons. The larger and straight 8 mm head and shaft probe was preferred as it facilitated stability, ease of anal insertion, and possible UHF technique including 128 piezoelectric elements in a linear array. We hereby present the procedure and considerations behind the development of a proposed new UHF transrectal pediatric probe. Such a device can open new possibilities for the diagnostics of pediatric anorectal conditions.

Ultra-High Frequency Ultrasound Imaging of Bowel Wall in Hirschsprung's Disease-Correlation and Agreement Analyses of Histoanatomy.

Hirschsprung's disease (HD) is characterized by aganglionosis in the bowel wall, requiring resection. Ultra-high frequency ultrasound (UHFUS) imaging of the bowel wall has been suggested to be an instantaneous method of deciding resection length. The aim of this study was to validate UHFUS imaging of the bowel wall in children with HD by exploring the correlation and systematic differences between UHFUS and histopathology. Resected fresh bowel specimens of children 0-1 years old, operated on for rectosigmoid aganglionosis at a national HD center 2018-2021, were examined ex vivo with UHFUS center frequency 50 MHz. Aganglionosis and ganglionosis were confirmed by histopathological staining and immunohistochemistry. Histoanatomical layers of bowel wall in histopathological and UHFUS images, respectively, were outlined using MATLAB programs. Both histopathological and UHFUS images were available for 19 aganglionic and 18 ganglionic specimens. The thickness of muscularis interna correlated positively between histopathology and UHFUS in both aganglionosis (R = 0.651, p = 0.003) and ganglionosis (R = 0.534, p = 0.023). The muscularis interna was systematically thicker in histopathology than in UHFUS images in both aganglionosis (0.499 vs. 0.309 mm; p < 0.001) and ganglionosis (0.644 versus 0.556 mm; p = 0.003). Significant correlations and systematic differences between histopathological and UHFUS images support the hypothesis that UHFUS reproduces the histoanatomy of the bowel wall in HD accurately.

Diagnostic Efficacy of Rectal Suction Biopsy with Regard to Weight in Children Investigated for Hirschsprung's Disease.

BACKGROUND/AIM: Diagnostic efficacy, defined as the percentage of rectal suction biopsy (RSB) specimens sufficient enough to determine the absence of ganglia cells in Hirschsprung's disease (HD) diagnosis, has been reported to be low, requiring repeated biopsies. The aim was to explore whether RSB diagnostic efficacy was influenced by the child's weight and to ascertain whether RSB efficacy differed between aganglionic and ganglionic tissue. MATERIALS AND METHODS: Efficacy analyses were conducted in a national HD-center's register on children 0-15 kg, examined between 2011-2019. First-time RSB diagnostic efficacy was correlated to the children's weight and final HD diagnosis. RESULTS: Among the 84 children who had first-time RSB, the overall diagnostic efficacy was 85% (71/84). The efficacy was higher among children weighing less than the identified cut-off of 9.0 kg (89% in 0-9.0 kg versus 62% in 9.01-15.0 kg, p = 0.026). Among children diagnosed with HD, 96% (26/27) weighed 0-9.0 kg. In this weight group, the diagnostic efficacy was lower in aganglionosis compared to ganglionosis (77%; 20/26 versus 96%; 43/45), p = 0.045). CONCLUSIONS: The RSB diagnostic efficacy was significantly higher in children weighing less than 9.0 kg and was less in aganglionic compared to ganglionic tissue. Therefore, weight can be useful to predict RSB diagnostic efficacy.

Ultra high frequency ultrasonography to distinguish ganglionic from aganglionic bowel wall in Hirschsprung disease: A first report.

BACKGROUND/PURPOSE: In Hirschsprung disease (HD) surgery, confirming ganglionic bowel is essential. A faster diagnostic method than the current frozen biopsy is desirable. This study investigated whether aganglionic and ganglionic intestinal wall can be distinguished from each other by ultra high frequency ultrasound (UHF ultrasound). METHODS: In an HD center during 2019, intestinal walls of recto-sigmoid specimens from HD patients were examined ex vivo with a 70 MHz UHF ultrasound transducer. Data from four sites were described. Histopathologic analysis was compared to the ultrasonography outcome at each site. Each patient's specimen served as its own control. RESULTS: 11 resected recto-sigmoid specimens (median 20 cm long [range 6.5-33]) with transition zones of 5 cm (2-11 cm) were taken from children aged 22 days (13-48) weighing 3668 g (3500-5508); 44 key sites were analyzed. There was full concordance for 42/44 (95%) key sites and 10 of 11 (91%) specimens. The specimen with discordance of two key sites contained a segment of aganglionosis (3 cm) and a transition zone (1 cm): the site discordance was limited to the transition zone ends. CONCLUSIONS: This first report on UHF ultrasound in recto-sigmoid HD shows promising results in identifying aganglionosis, transition zones and ganglionic bowel. Further in vivo studies are required.

Identification of Warning Signs During Selection of Surgical Trainees.

OBJECTIVE: The aim was to document empirical observations about antecedents to and practices of unsuitable behaviours amongst surgical trainees and develop an interview guide that could be used for the selection process. DESIGN: A mixed methods design was adopted combining a survey distributed to senior surgeons and heads of departments, followed by semi-structured interviews with experienced surgeons. SETTING: All surgical departments and hospitals in The South Swedish Health Care Region. PARTICIPANTS: The survey was completed by 54 of 83 eligible surgeons above 50years of age, and 4 of 7 heads of surgical departments. Semi-structured interviews with 13 surgeons representing local, regional, and university hospitals from the same cohort. RESULTS: Forty-six (85%) surgeons and four of seven heads of departments responded that they had come across surgical trainees deemed unsuitable to train and work as a surgeon. All heads of department and 31 of 54 of the surgeons believed tendencies towards unsuitability are evident early during training. From the survey, 107 statements described reasons for finding a trainee unsuitable. Qualitative analysis of the interviews and free-text answers of the survey led to identification of 11 problem domains with associated "warning signs". An interview guide to help detect unsuitability tendencies in candidates during selection procedures was constructed. CONCLUSIONS: Experienced surgeons have quite consistent views on what makes a person unsuitable as a surgeon. Their views have been systematized into 11 problem domains, and a set of 'warning signs' for unsuitable behaviours and traits has been developed. Early detection of these signs and traits is important for the individual, the work environment, and patient safety. A recommendation for a minimum framework for selection including the constructed interview guide is presented.

Children with Hirschsprung's Disease and Syndromes with Cognitive Dysfunction: Manifestations, Treatment, and Outcomes.

Introduction To assess differences in initial symptoms, treatments, and bowel function between children with Hirschsprung's disease (HD) with or without a cognitive dysfunction (CD). Materials and Methods The study included children with HD who underwent transanal endorectal pull-through. A retrospective chart review was performed to collect data on patient characteristics, diagnosis, and treatment. Data on bowel symptoms in children older than 4 years without a colostomy were compiled during a cross-sectional, patient-reported follow-up. Results Fifty-three children with HD were included; of these, 12 (23%) had CD. The median birth weight was lower, frequency of vomiting as the presenting symptom was lower, and time until the first contact with a pediatric surgeon was higher in children with CD than in those without (3,295 vs. 3,623 g, p = 0.013; 28 vs. 66%, p = 0.02; and 4 days vs. 1 day, p = 0.048, respectively). At follow-up, 5 (15%) of 33 children aged over 4 years had CD. More children without CD had some ability to hold back defecation and sense the urge to defecate than those with CD ( p = 0.002 and p = 0.001, respectively). Conclusion HD children who have CD present with different initial symptoms, have a delay in the first consultation with a pediatric surgeon, and experience poorer bowel function outcomes than HD children without CD. Therefore, HD children with CD should receive special attention in both clinical practice and research.

Urinary tract anomalies and urinary tract dysfunction in children with Hirschsprung disease-Is follow-up indicated?

BACKGROUND/PURPOSE: Urinary tract function in children with Hirschsprung disease (HD) is rarely considered. AIM: to evaluate the prevalence of urinary tract anomalies and dysfunction in children with HD compared to controls. METHODS: This was an observational cross sectional case-control study. Children with HD who underwent transanal endorectal pull-through technique (TERPT) from 2005 to 2017 were invited to participate. Ultrasound of the urinary tract was performed postoperatively. Children >4 years were asked to answer a urinary tract function questionnaire. Controls were age-matched healthy children. Ethical approval was obtained. RESULTS: Seventy two children with HD and TERPT were included. Ultrasound was performed in 58 children (83%) post-TERPT. Ten anomalies were diagnosed in six children (10%). Structural anomalies included abnormal kidney size (7%), renal agenesis (2%), prominent calyces (2%) and renal pelvis anomaly (25). Probable acquired anomalies included hydronephrosis (2%), hydroureter (2%) and parenchymal damage (2%). One child had a prior nephrectomy owing to a Wilms' tumor. All 37 children >4 years (27 boys and 10 girls), median aged 8 years (range 4-12), answered the questionnaire as did 284 healthy controls (144 boys and 140 girls). Boys with HD reported a higher frequency of enuresis: 65% versus 9% (p = 0.001) and urinary tract infections: 18% versus 3% (p = 0.012). Girls with HD reported enuresis more frequently (60%) than healthy girls (7%) (p = 0.001). Children with HD with constipation reported enuresis more frequently (p = 0.038). CONCLUSIONS: Urinary tract anomalies and dysfunction deserve attention in the follow-up of children with HD. We suggest screening for urinary tract anomalies and urinary tract symptoms in follow-up of children with HD. TYPE OF STUDY: Treatment study. LEVEL: III.

Treatment and Patient Reported Outcome in Children with Hirschsprung Disease and Concomitant Congenital Heart Disease.

Purpose. Congenital heart disease (CHD) is reported to be associated with Hirschsprung disease (HD). The aim was to evaluate any differences between children with HD with and without CHD, respectively, with regard to patient characteristics, medical care, and patient reported bowel function. Method. This is a retrospective chart study and a cross-sectional long-term follow-up of patients older than 4 years old, including all children with HD operated on with transanal endorectal pull-through (TERPT) at a tertiary center of pediatric surgery. Information about patient characteristics, diagnostics, surgery, and medical care was compiled. At long-term follow-up, bowel function was assessed by Bowel Function Score. Results. Included were 53 HD-patients, 13 with CHD and 40 without CHD. Children with CHD more commonly presented with failure to thrive; 4 (23%) compared to those without CHD (0%) (p < 0.01). In the long-term follow-up, including 32 patients (6 with CHD), constipation was more commonly reported by children with CHD 5 (83%) than by children without CHD 4 (27%) (p = 0.01). No differences were shown in the other parameters such as fecal control and incontinence. Conclusion. HD-patients with CHD more commonly presented with failure to thrive and more frequently reported constipation than HD-patients without CHD. The findings indicate that HD-patients with CHD might need special consideration in their initial care and long-term follow-up.

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.