Bowel function and associated risk factors at preschool and early childhood age in children with anorectal malformation type rectovestibular fistula: An ARM-Net consortium study.

BACKGROUND: Outcome of patients operated for anorectal malformation (ARM) type rectovestibular fistula (RVF) is generally considered to be good. However, large multi-center studies are scarce, mostly describing pooled outcome of different ARM-types, in adult patients. Therefore, counseling parents concerning the bowel function at early age is challenging. Aim of this study was to evaluate bowel function of RVF-patients at preschool/early childhood age and determine risk factors for poor functional outcome. METHODS: A multi-center cohort study was performed. Patient characteristics, associated anomalies, sacral ratio, surgical procedures, post-reconstructive complications, one-year constipation, and Bowel Function Score (BFS) at 4-7 years of follow-up were registered. Groups with below normal (BFS < 17; subgroups 'poor' ≤ 11, and 'fair' 11 < BFS < 17) and good outcome (BFS ≥ 17) were formed. Univariable analyses were performed to detect risk factors for outcome. RESULTS: The study included 111 RVF-patients. Median BFS was 16 (range 6-20). The 'below normal' group consisted of 61 patients (55.0%). Overall, we reported soiling, fecal accidents, and constipation in 64.9%, 35.1% and 70.3%, respectively. Bowel management was performed in 23.4% of patients. Risk factors for poor outcome were tethered cord and low sacral ratio, while sacral anomalies, low sacral ratio, prior enterostomy, post-reconstructive complications, and one-year constipation were for being on bowel management. CONCLUSIONS: Although median BFS at 4-7 year follow-up is nearly normal, the majority of patients suffers from some degree of soiling and constipation, and almost 25% needs bowel management. Several factors were associated with poor bowel function outcome and bowel management. LEVEL OF EVIDENCE: Level III.

Use of 5-mm Staple in Neonatal Intestinal Surgery.

Introduction: The use of staples to perform intestinal anastomosis in children has gained popularity in the past years. The aim of this study is to evaluate the outcomes of pediatric patients who underwent intestinal anastomosis with a 5-mm staple in a tertiary health care center. Material and Methods: From April 2017 to November 2019, the records of all pediatric patients who underwent intestinal anastomosis with a 5-mm staple were retrospectively revised. The reconstruction technique was functional end-to-end anastomosis. Results: A total of 12 intestinal anastomoses were evaluated. Mean age at surgery was 120 days. Small bowel anastomosis was the most frequently performed procedure (eight cases). Stapling difficulties were found in 3 patients. The anastomosis could not be performed with the 5-mm endostapler in one of these patients. The median follow-up was 26 months (interquartile range 20-40 months). Postoperative complications included one bowel obstruction that was surgically treated. Conclusions: Mechanical suturing with 5-mm staple is a safe alternative technique to perform intestinal anastomosis in neonates and infants. The use of this staple has proven to be safe and feasible in pediatric patients. It is necessary to select patients carefully according to their bowel characteristics.

Impact of the appendiceal position on the diagnosis and treatment of pediatric appendicitis / Impacto da posição do apêndice sobre o diagnóstico e tratamento de apendicite da infância

ABSTRACT Objective: To investigate how symptoms vary according to the appendiceal position in pediatric patients and to demonstrate that the laparoscopic approach is safe and effective in any appendiceal location by comparing each location to another. Methods: The medical records of 1,736 children aged 14 or younger who underwent laparoscopic appendectomy over a period of 14 years were analyzed retrospectively. Patients were divided according to the position of the appendiceal tip into four groups: anterior, pelvic, retrocecal and subhepatic. The Kruskal-Wallis and chi-square tests were used with the Bonferroni correction, with a significant p<0.05. Results: The appendiceal location was anterior in 1,366 cases, retrocecal in 248 cases, pelvic in 66 cases and subhepatic in 56 cases. There were no significant differences between the groups in terms of patient age and gender. Abdominal pain was the only symptom with statistically significant differences between the groups. The rate of perforated appendicitis was higher in the subhepatic and pelvic positions. Intraoperative complications and conversions were not statistically significant. Technical difficulties and operative time were higher in subhepatic position. The rate of postoperative complications was similar between the different locations, except for bowel obstruction, which was higher in pelvic appendicitis. Conclusions: The clinical symptoms of appendicitis hardly ever change with the position of the appendix. The laparoscopic approach is safe and effective, regardless the appendiceal location.

RESUMO Objetivo: Investigar como os sintomas variam de acordo com a posição do apêndice em pacientes pediátricos e demonstrar que a laparoscopia é segura e eficaz em qualquer posição do apêndice, comparando-as. Métodos: Os prontuários de 1.736 pacientes pediátricos com idade ≤14 anos submetidos à apendicectomia laparoscópica em um período de 14 anos foram analisados retrospectivamente. Os pacientes foram divididos de acordo com a posição do apêndice: anterior, pélvica, retrocecal e sub-hepático. Os testes de Kruskal-Wallis e do qui-quadrado foram usados com a correção de Bonferroni, sendo significante p<0,05. Resultados: A posição do apêndice era anterior em 1.366 casos, retrocecal em 248 casos, pélvica em 66 casos e sub-hepática em 56 casos. Não houve diferenças significativas entre os grupos quanto às variáveis idade e sexo. A dor abdominal foi a única variável com diferenças estatisticamente significantes entre os grupos. A taxa de apêndice perfurado foi superior nas posições sub-hepática e pélvica. As complicações intraoperatórias e a taxa de conversão não foram estatisticamente significativas. As dificuldades técnicas e o tempo cirúrgico foram superiores em posição sub-hepática. A taxa de complicações pós-operatórias foi semelhante entre as diferentes posições, exceto a obstrução intestinal, que foi superior em posição pélvica. Conclusões: Os sintomas da apendicite dificilmente variam com a posição do apêndice. A laparoscopia é segura e eficaz, independentemente da posição do apêndice.

IMPACT OF THE APPENDICEAL POSITION ON THE DIAGNOSIS AND TREATMENT OF PEDIATRIC APPENDICITIS.

OBJECTIVE: To investigate how symptoms vary according to the appendiceal position in pediatric patients and to demonstrate that the laparoscopic approach is safe and effective in any appendiceal location by comparing each location to another. METHODS: The medical records of 1,736 children aged 14 or younger who underwent laparoscopic appendectomy over a period of 14 years were analyzed retrospectively. Patients were divided according to the position of the appendiceal tip into four groups: anterior, pelvic, retrocecal and subhepatic. The Kruskal-Wallis and chi-square tests were used with the Bonferroni correction, with a significant p<0.05. RESULTS: The appendiceal location was anterior in 1,366 cases, retrocecal in 248 cases, pelvic in 66 cases and subhepatic in 56 cases. There were no significant differences between the groups in terms of patient age and gender. Abdominal pain was the only symptom with statistically significant differences between the groups. The rate of perforated appendicitis was higher in the subhepatic and pelvic positions. Intraoperative complications and conversions were not statistically significant. Technical difficulties and operative time were higher in subhepatic position. The rate of postoperative complications was similar between the different locations, except for bowel obstruction, which was higher in pelvic appendicitis. CONCLUSIONS: The clinical symptoms of appendicitis hardly ever change with the position of the appendix. The laparoscopic approach is safe and effective, regardless the appendiceal location.