Use of expedited post-operative protocol for children undergoing appendicostomy reduces length of hospitalization.

BACKGROUND: An appendicostomy (ACE) is a surgical option for antegrade enemas in children with severe constipation and/or fecal incontinence who have failed medical management.  In 2019, we initiated an expedited post-operative protocol and sought to examine our short-term outcomes compared with our historical cohort. METHODS: A retrospective review was performed of all children undergoing ACE between 2017 and 2020. Children were excluded if they underwent an associated procedure (e.g. colon resection). Patients were divided into two cohorts: historical cohort (2017-2018, Group A) and the expedited protocol (2019 to present, Group B). The primary outcome was length of stay. RESULTS: 30 patients met inclusion (Group A = 16, Group B = 14). The most common indications for ACE were constipation (50%) and constipation or fecal incontinence associated with anorectal malformation (43%). Group B experienced a decreased length of stay (1 vs 3 days, P = 0.001) without differences in 30-day surgical site infection (7.1% vs 18.8%, p = 0.61) or unplanned visit (15.4% vs 18.8%, p = 1.0). Group B had a higher prevalence of MiniACE® button placed through the appendix vs. Malone (42.8% vs 12.5%, p = 0.10). CONCLUSIONS: Our expedited post-op protocol decreased length of stay without other significant adverse clinical sequelae. LEVEL OF EVIDENCE: Retrospective Comparative Study, Level III.

Use of an enterocolitis triage and treatment protocol in children with Hirschsprung disease reduces hospital admissions.

BACKGROUND: While a consensus for the definition of Hirschsprung associated enterocolitis (HAEC) is lacking, the mainstay of treatment includes rectal irrigations with or without antibiotics. This treatment is often effective when initiated as an outpatient. Our institution implemented a triage algorithm in an effort to standardize care thus providing more timely treatment and preventing unnecessary hospital admissions. We sought to review our short-term experience. METHODS: A retrospective review was performed of all Hirschsprung (HD) patients <6 years old over two distinct time periods from May 2016-2017 (pre-protocol, group A) and June 2017-2018 (post-protocol, group B). Patients with a colostomy were excluded. Primary end point was hospital admission. Presenting symptoms were categorized as moderate or severe, with patient triage based on number and quality of symptoms. RESULTS: Eighty-seven total patients were included. Rectosigmoid transition zone was most common (75%) and 20% of patients had trisomy 21. HAEC occurred in 22% of patients in the preprotocol group (group A, n = 78, 27 episodes) and 20% of patients in the post-protocol group (group B, n = 87, 32 episodes). In group A, 78% of episodes required an unplanned visit and 74% resulted in admission. In group B, 81% of episodes required an unplanned visit and 50% resulted in admission (33% reduction in hospital admission, p = 0.06). Irrigations only, without antibiotics, were used in 30% of episodes in group A versus 41% in group B. Of patients who initially contacted the office by phone (group A = 7 episodes, group B = 6 episodes), outpatient management was successful in 43% versus 100% respectively (p = 0.07). No patient experienced increased morbidity in group B. DISCUSSION: Implementation of a HAEC treatment algorithm shows promise in improving the management and resource utilization of this complex patient population. It is anticipated that continued education of caregivers and the treatment team will result in a greater effect. A multi-institutional implementation of this algorithm is needed to characterize risk factors associated with failure of outpatient management. LEVEL OF EVIDENCE: III, Treatment Study.

Intermediate and long-term outcomes of a bowel management program for children with severe constipation or fecal incontinence.

PURPOSE: We sought to examine the long-term clinical success rates of a bowel management program (BMP) for children with severe constipation or fecal incontinence. METHODS: A single center review was conducted of children (≤18 years) enrolled in a BMP and followed in a colorectal specialty clinic (2011-2017). All patients who completed an initial week of the BMP were included. Patients enrolled in a BMP after 2018 were excluded. Success was defined as no accidents and <2 stool smears per week. RESULTS: A total of 285 patients were reviewed. BMP was initiated at a median age of 7 years (9 months-17 years). Primary diagnoses included functional constipation (112), anorectal malformation (ARM) (104), Hirschsprung Disease (HD) (41), rectal prolapse (14), spina bifida (6), fecal incontinence (3) and other (5; 4 sacral coccygeal teratomas and a GSW to the buttocks). Initial bowel regimen included large volume enema in 54% and high dose stimulant laxative in 46%. The initial Bowel Management Week (BMW) was successful in 233 (87% of adherent patients) patients with 17 (6%) non-adherent. One hundred twenty-two patients had follow-up at 12 months (72% success amongst adherent patients, 7% of patient non-adherent) and 98 patients had follow-up at 24 months (78% success amongst adherent patients, 10% of patients non-adherent). 21/154 (14%) patients started on enemas were later successfully transitioned to laxatives and 13/132 (10%) patients started on laxatives subsequently required enemas in order to stay clean. Clinic phone contact occurred outside of scheduled visits for adjustment to the BMP in 44% of patients. 33% of patients had surgery to aid bowel management (antegrade colonic enema (ACE) = 81, resection + ACE = 13, diverting stoma = 4). Median follow up was 2.5 years (5 weeks-7 years). CONCLUSION: Children who follow a structured BMP with readily available personnel to provide outpatient assistance can experience successful treatment of severe constipation or fecal incontinence long-term. A multi-institutional collaboration is necessary to identify factors which predict failure of a BMP and non-adherence. TYPE OF STUDY: Single-center retrospective chart review. LEVEL OF EVIDENCE: 3.

The effect of multidisciplinary colorectal center development on short-term hospital readmissions for patients with anorectal malformations or Hirschsprung disease.

INTRODUCTION: Hospital readmissions have become a quality metric for both hospital systems and individual surgeons. The medical literature is replete with studies describing readmission rates and factors contributing to readmissions following surgical procedures. Relatively little, however, has been done to define potential solutions to these problems. Over the past decade there has been a movement toward the development of multidisciplinary colorectal centers at high volume children's hospitals. We hypothesized that the development of a colorectal center at our children's hospital decreased readmissions in our colorectal surgery population. MATERIALS AND METHODS: A retrospective review was performed including all patients with the diagnosis of anorectal malformation (ARM) or Hirschsprung disease (HD) at our institution between the years of 2005-2017. Patient level outcomes were compared between the cohort treated prior to (2005-2010) and the cohort treated after the development of the colorectal center (2012-2017). RESULTS: A total of 354 patients were identified. One hundred seventy-eight patients (113 ARM, 65 HD) were treated prior to and 176 patients (110 ARM, 66 HD) were treated after the development of the colorectal center. Forty-five (25.3%) patients underwent neonatal repair prior to development of the center compared to 15 (8.5%) after. 111 (62.4%) patients underwent colostomy prior to the colorectal center comparted to 95 (54%) after. The rate of readmission within 120 days of discharge in the early group was 63% compared to 52% in those managed in the multidisciplinary colorectal center (p = 0.04). Conversely, the rate of emergency room visits increased from 8.4% to 27.3% (p = 0.01). The decrease in readmission rates was more pronounced in the ARM group, while the HD cohort had similar readmission rates before and after the establishment of the center. Multivariate logistic regression revealed an odds ratio of 0.59 (95% CI 0.37-0.92) for readmission following the development of the multidisciplinary colorectal center. DISCUSSION: The development of a multidisciplinary colorectal center at our institution was associated with decreased hospital readmissions, but an increase in emergency department resource utilization. These findings suggest improved efficiency in patient care with the implementation of a multispecialty, patient centered approach while also identifying areas of focus for future quality improvement initiatives. LEVEL OF EVIDENCE: Level III, retrospective comparative study.