Residential Redlining, Neighborhood Trajectory, and Equity of Breast and Colorectal Cancer Care.

OBJECTIVE: This study aimed to determine the influence of structural racism, vis-à-vis neighborhood socioeconomic trajectory, on colorectal and breast cancer diagnosis and treatment. SUMMARY BACKGROUND DATA: Inequities in cancer care are well documented in the United States but less is understood about how historical policies like residential redlining and evolving neighborhood characteristics influence current gaps in care. METHODS: This retrospective cohort study included adult patients diagnosed with colorectal or breast cancer between 2010 and 2015 in 7 Indiana cities with available historic redlining data. Current neighborhood socioeconomic status was determined by the Area Deprivation Index (ADI). Based on historic redlining maps and current ADI, we created four "Neighborhood Trajectory" categories: Advantage Stable, Advantage Reduced, Disadvantage Stable, Disadvantage Reduced. Modified Poisson regression models estimated the relative risks (RR) of Neighborhood Trajectory on cancer stage at diagnosis and receipt of cancer-directed surgery (CDS). RESULTS: A final cohort derivation identified 4,862 cancer patients with colorectal or breast cancer. Compared to Advantage Stable neighborhoods, Disadvantage Stable neighborhood was associated with late-stage diagnosis for both colorectal and breast cancer (RR=1.30 [95% CI=1.05 - 1.59]; RR=1.41 [1.09 - 1.83], respectively). Black patients had lower likelihood of receiving CDS in Disadvantage Reduced neighborhoods (RR=0.92 [0.86 - 0.99]) than White patients. CONCLUSIONS: Disadvantage Stable neighborhoods were associated with late-stage diagnosis for breast and colorectal cancer. Disadvantage Reduced (gentrified) neighborhoods were associated with racial-inequity in CDS. Improved neighborhood socioeconomic conditions may improve timely diagnosis but could contribute to racial inequities in surgical treatment.

Protocolized management of pediatric complicated appendicitis leads to improved outcomes.

PURPOSE: We aimed to evaluate a complicated appendicitis clinical practice guideline at our institution. METHODS: Records were compared before and after protocol implementation. We standardized an ED consult pathway, antibiotic use and need for early appendectomy (EA) versus interval appendectomy (IA). We evaluated demographics, clinical characteristics, and outcomes. Subgroup analysis was performed to compare patients with small abscess treated with IA pre-protocol versus similar patients treated by EA post-protocol. RESULTS: In total 246 patients were reviewed (Pre-protocol = 152, Post-protocol = 94). Pre-protocol early appendectomy rate was 51% versus 82% on post-protocol patients. There were no differences in demographics. Post-protocol the use of preoperative imaging significantly decreased (Pre 92% vs. 56%, p = 0.0001), as well as the use of discharge antibiotics (Pre 93% vs. Post 27%, p = 0.0001) with no change in abscess rate. Overall, post-protocol patients had fewer total CT scans performed (Pre 40% vs. Post 28%, p = 0.03) and decreased total length of stay (Pre 7.7 vs. Post 6.5 days, p = 0.049). On subgroup analysis, post-protocol EA with no or small abscess had lower median number of admissions, decreased total LOS (Pre IA 9 days vs. Post EA 5 days, p = 0.00001) and fewer complications (Pre IA 42% vs. EA 22%, p = 0.022). CONCLUSION: The establishment of a standardized pediatric complicated appendicitis protocol may lead to improved outcomes and resource utilization. Patients presenting with no or small abscess may be the least likely to benefit from interval appendectomy. LEVEL OF EVIDENCE: Level III.

Screening Laboratory Testing in Asymptomatic Minor Pediatric Blunt Trauma Leads to Unnecessary Needle Sticks.

OBJECTIVE: Screening blood work after minor injuries is common in pediatric trauma. The risk of missed injuries versus diagnostic necessity in an asymptomatic patient remains an ongoing debate. We evaluated the clinical utility of screening blood work in carefully selected asymptomatic children after minor trauma. METHODS: Patients seen at a level 1 pediatric center with "minor trauma" for blunt trauma between 2010 and 2015 were retrospectively reviewed. Exclusion criteria were age <4 of >18 years, a Glasgow Coma Scale score of <15, penetrating trauma, nonaccidental trauma, hemodynamic instability, abdominal findings (pain, distension, bruising, tenderness), hematuria, pelvic/femur fracture, multiple fractures, and operative intervention. Data abstraction included demographics, blood work, interventions, and disposition. RESULT: A total of 1308 patients were treated during the study period. Four hundred thirty-three (33%) met inclusion criteria. Mean ± SD age was 12.7 ± 4 years (range, 4-18 years), and 59% were male. Seventy-eight percent were discharged home from the emergency department. All patients had blood work. Twenty-eight percent had at least one abnormal laboratory value. The most common abnormal blood work was leukocytosis (16%). Thirty percent had an intervention, and none prompted by abnormal blood work. One patient had an intra-abdominal finding (psoas hematoma). CONCLUSION: When appropriately selected, screening laboratory testing in asymptomatic minor pediatric blunt trauma patients leads to unnecessary needle sticks without significant advantage.

Standardized text messages improve 30-day patient follow-up for ACS pediatric NSQIP cases.

PURPOSE: Thirty-day follow-up is a critical and challenging component of the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP). We hypothesized the simplicity and immediacy of text messaging would increase response rates while reducing workload. METHODS: For 6 months, text messages were the primary form of contact for first and second follow-up attempts. If no response, a phone call was made. Results of this protocol were compared to the previous 6 months when phone calls were the primary method. RESULTS: The text message (TM) group had 298 cases and phone call (PC) group had 354. The first contact was successful in 63.8% of the TM group compared to 47.5% of the PC group. The second contact was successful in 15.4% (TM) and 16.9% (PC). In the third attempt, 3.0% answered the call in the TM group versus 9.3% in the PC group. Some families remained unreachable: 17.8% in TM group and 26.3% in PC group (p = 0.01). When totaled, time spent to obtain caregivers' responses was over five times higher in the PC group (910 min) than the TM group (173 min) (p = 0.005). CONCLUSION: Patient follow-up using text messaging has improved our follow-up rate while decreasing workload.

Laparoscopic-assisted divided colostomy for anorectal malformation case series: a description of technique, clinical outcomes and a review of the literature.

OBJECTIVE: To present a case series of pediatric patients who underwent a laparoscopic-assisted divided colostomy for anorectal malformations, describe our technique, and provide a review of the literature on laparoscopic-assisted colostomy in pediatric patients. METHODS: We performed a retrospective review of six patients born with anorectal malformations, who received a laparoscopic-assisted colostomy from 2012 to 2016 at Cardinal Glennon Children's Medical Center. RESULTS: The average operating time was 74.5 min. Laparoscopic colostomy types included divided (n = 5) and end colostomy with Hartmann's (n = 1). Location of the colostomy was selected just distal to the descending colon (n = 5) or at the sigmoid flexure (n = 1). Feeds and stoma production was achieved within 24 h from surgery in most patients. There were no major complications except one patient having a mucosal fistula prolapse that was easily reduced. CONCLUSIONS: Laparoscopic-assisted colostomy in the management of anorectal malformations is a safe and effective technique. It offers similar advantages of the open technique, with the added benefits of avoiding wound-related complications and improved cosmetic results.

Imaging for acute appendicitis at nonpediatric centers exposes children to excess radiation.

BACKGROUND: Radiation exposure is the reason for the decreased utilization of computed tomography (CT) in pediatric centers (PCs). We sought to compare the radiation dose exposure of CT imaging performed at outside hospitals (OH) versus PC in pediatric patients with acute appendicitis (AA). MATERIAL AND METHODS: A retrospective review of all patients managed at our PC for AA from January 2011 to March 2016 was performed. Patients who had CT imaging for AA at OH were compared to those who underwent CT for appendicitis at our PC. Radiation dosing was compared using the dose index (CTDI [mGY]) and dose length product (DLP [mGYcm]). Independent t-test samples were used to compare means for radiation dose. RESULTS: 379 patients met inclusion criteria. There were 59.4% (225) patients imaged at our PC and 40.6% (154) patients were transferred from an OH. When performed at OH, 6.5% of CTs were considered inadequate as they were done without intravenous contrast compared to 1.3% in our PC. Mean CTDI was 6.9 at our PC and 11.8 at OH (P < 0.0001). Mean DLP at PC was 296.2 versus 456.8 at OH (P < 0.0001). An excess radiation dose of 4.9 mGY and 160.5 mGYcm was noted when CT scan was performed at OH versus PC. CONCLUSIONS: Using DLP as a gauge of radiation exposure, CT imaging performed at OH has a 44% higher radiation rate relative to the exposure at PC. In cases of suspected AA at a facility without pediatric surgeons, early transfer to PC prior to imaging is advocated.

Optimal timing of cholecystectomy in children with gallstone pancreatitis.

BACKGROUND: Little data exist regarding the recurrence of pancreatitis in pediatric patients with gallstone pancreatitis awaiting cholecystectomy. This study evaluates the recurrence rate of pancreatitis after acute gallstone pancreatitis based on the timing of cholecystectomy in pediatric patients. MATERIALS AND METHODS: A retrospective chart review of all patients admitted with gallstone pancreatitis from 2007 to 2015 was performed. Children were divided into the following five groups. Group 1 had surgery during the index admission. Group 2 had surgery within 2 wk of discharge. Group 3 had surgery between 2 and 6 wk postdischarge. Group 4 had surgery 6 wk after discharge, and group 5 patients had no surgery. The recurrence rates of pancreatitis were calculated for all groups. RESULTS: Forty-eight patients with gallstone pancreatitis were identified in this study. The 19 patients in group 1 had no recurrence of their pancreatitis. Of the remaining 29 patients, nine (31%) had recurrence of pancreatitis or required readmission for abdominal pain prior to their cholecystectomy. In group 2, two of the eight patients (25%) had recurrent pancreatitis. In group 3, three of eight patients (37.5%) developed recurrent pancreatitis. In group 4, three of five patients (60%), and in group 5, one of eight. No children in group 5 had demonstrable gallstones at presentation, only sludge in their gallbladder. CONCLUSIONS: Cholecystectomy during the index admission is associated with no recurrence or readmission for pancreatitis. Therefore, we recommend that cholecystectomy be performed after resolution of an episode of gallstone pancreatitis during index admission.

Utility of hospital admission for pediatric intussusceptions.

PURPOSE: The standard practice in pediatric patients diagnosed with intussusception has been reduction via enema and admission for a period of nil per os and observation. Little data exists to support this practice. The objective of this study was to examine whether post-reduction admission to hospital is required. METHODS: A retrospective chart review was performed on all patients aged 0-18 years old with intussusception over a span of 20 years. Study included children treated for intussusception on first encounter with enema and subsequently admitted for observation. Study excluded those readmitted for recurrence after 48 h, patients whose intussusception did not reduce on first try, those lost to follow-up, and those who went to the operating room. Early recurrence was defined as recurrence within 48 h post-reduction. RESULTS: Out of 171 patients admitted, only one experienced an early recurrence (0.6 %). Median length of stay for all patients was 2 days. Average cost incurred per day for intussusception admission was $404. CONCLUSION: Intussusception in a child that is successfully reduced via enema has a low recurrence rate and is usually followed by prompt resolution of symptoms. An abbreviated period of observation in the emergency department post-reduction may result in healthcare savings.

Role of computed tomography and clinical findings in pediatric blunt intestinal injury: a multicenter study.

PURPOSE: Although computed tomographic (CT) scans are accurate in diagnosing solid-organ injuries, their ability to diagnose a blunt intestinal injury (BII) is limited, occasionally requiring repeated imaging. The purpose of this study was to evaluate the role of clinical findings as well as original and repeated CT imaging in the ultimate decision to operate for BII. METHODS: An 18-institution record review of children (≤ 15 years) diagnosed with a BII confirmed during surgery between 2002 and 2007 was conducted by the American Pediatric Surgery Association Trauma Committee. The incidence of imaging, repeated imaging, and final reported indications for operative exploration were evaluated. RESULTS: Among 331 patients identified with a BII, 292 (88%) underwent at least 1 abdominal CT scan. Sixty-two (19%) underwent at least 1 repeated scan before operation. Forty-seven percent of children who underwent a CT scan were taken to the operating room based primarily on clinical indications (fever, abdominal pain, shock or elevated white blood cell count), whereas 31% were operated on based on both a clinical and CT indication and 22% were operated on based on a CT indication alone (P < 0.001). Although free air was the most common radiographic indication for surgery, 13% of patients with a repeated scan had free air diagnosed on their first CT. Most children undergoing a repeated CT (84%) had findings on the original scan suggesting a BII. Among the 10 patients whose first CT scan result was normal, only 1 went to the operating room based only on radiographic findings. Children who had their first CT scan at a referring hospital were more likely to have a repeated study compared with those imaged at a trauma center (33% vs 13%, P < 0.0001). CONCLUSIONS: Although abdominal CT imaging may contribute to diagnosing intestinal injury after blunt trauma, most children undergo operation based on clinical findings. Repeated imaging should be limited to select patients with diagnostic uncertainty to avoid unneeded delay and radiation exposure.

To Button or Not to Button? Primary Gastrostomy Tubes Offer No Significant Advantage Over Buttons.

Purpose: Outcomes between primary gastrostomy tubes and buttons (G-tube and G-button) have not been established in pediatric patients. We hypothesized that primary G-tube have decreased complications when compared to G-button. Methods: A retrospective review of surgically placed gastrostomy devices from 2010 to 2017 was performed. Data collected included demographics, outcomes and 90-day complications. We divided the patients into primary G-tube and primary G-button. Results: Of 265 patients, 142 (53.6%) were male. Median age and weight at the time of surgery were 7 months (interquartile range [IQR], 2-44 months) and 6.70 kg (IQR, 3.98-14.15 kg), respectively. Among the groups, G-tube had 80 patients (30.2%) while G-button 185 patients (69.8%). There were 153 patients with at least one overall complication within 90 days postoperative. There was no significant difference in overall complications between groups (G-tube 63.8% vs. G-button 55.7%, p=0.192). More importantly, there were no significant differences in major complications among the groups, G-tube vs. G-button (5% vs. 4%; p=0.455). Conclusion: Primary G-tube offers no significant advantage in overall, minor or major complications when compared to primary G-button.

Unnecessary imaging, not hospital distance, or transportation mode impacts delays in the transfer of injured children.

OBJECTIVES: Timely transfer of injured children to pediatric trauma centers (PTCs) that can address their unique needs is important. This study was designed to understand the characteristics of transferred injured children. METHODS: Data from our level I PTC over 5 years (2002-2006) were reviewed. Transferred patients were divided based on time from injury to arrival at our PTC: early (<2 hours) and late (>2 hours). Data collected included demographics, Injury Severity Scale score, Glasgow Coma Scale score, mode of transportation, referring hospital information including pretransfer imaging, and disposition from our emergency room. RESULTS: Seven hundred forty-eight patients were included. Eighty-two percent (n = 612) were in the late group and arrived, on average, 6 hours after those transferred early (420 vs 69.9 minutes, P < 0.05). Seventy-nine percent (n = 147) of transfers with severe injuries (Injury Severity Scale score >15) and 47% (n = 15) of those with severe head injuries (Glasgow Coma Scale score <8) arrived late. The disproportionate number of late transfers was consistent among all transferring hospitals regardless of distance and only slightly improved in the group transferred by air ambulance. In addition, those transferred late had significantly more pretransfer imaging (49% vs 23%, P = 0.0025). CONCLUSIONS: Despite the advantages of care in trauma centers, a significant number of severely injured children are transferred well beyond 2 hours after injury. This study has demonstrated that this pattern of delayed transfer is a systemic problem occurring among all transferring hospitals regardless of distance or mode of patient transfer and is associated with increased use of imaging before transfer.

Extended Antibiotic Course Prior to Interval Appendectomy in Children with Complicated Appendicitis Offers No Significant Advantage.

BACKGROUND: No consensus exists regarding duration of antibiotic therapy for complicated appendicitis treated with interval appendectomy. We hypothesized that more than two weeks of antibiotic therapy does not decrease complication rates in asymptomatic patients. PATIENTS AND METHODS: A retrospective review of all patients with complicated appendicitis treated with interval appendectomy from 2010-2015 was performed. We divided the patients in two groups (group 1, ≤2 weeks of antibiotics; group 2: >2 weeks of antibiotics). Demographics, antibiotic agents, and complications were collected. Pearson χ analysis and Student t-test analysis was performed with significance of p < 0.05. RESULTS: Total of 158 patients met inclusion criteria (group 1 [47.4%] vs. group 2 [52.5%]). Mean length of stay was 7.5 days. Abscess on admission was 26% (n = 41). The groups were demographically similar. Total complication rate was 39.2% (abscess development, n = 19; re-admissions, n = 16; interval appendectomy <28 days, n = 13; unplanned emergency department visits, n = 7; fistula, n = 4, wound infection/dehiscence, n = 3; and conversion to open surgery, n = 4). All fistulas and conversions occurred in the less than two-week group. Mean course of antibiotics was 4.1 weeks. There was no significant difference in the complication rates based on duration or type of antibiotics (p = 1.0). CONCLUSION: Treatment with more than two weeks of antibiotic therapy for complicated appendicitis does not confer any clinical benefit prior to interval appendectomy. Complications were not reduced by a prolonged course of antibiotic therapy.

Abscess and symptoms duration upon presentation should guide decision algorithms for early versus interval appendectomy in children.

BACKGROUND: To compare outcomes for complicated appendicitis treated with early versus interval appendectomy and to identify which patients would likely benefit from early appendectomy. METHODS: A retrospective review of complicated appendicitis was performed from 2010 to 2015. Patients were divided into early (EA) versus interval appendectomy (IA) groups. We compared demographics, complications and outcomes. Pearson's Chi square analysis and Student's T test analysis were performed. RESULTS: We identified 316 patients (EA group 53% vs. IA group 47%). Interval appendectomy group had longer symptom duration [IA 3.8 vs. EA 2.3 days (p = 0.0001)], increased leukocytosis [IA 18.7 vs. EA 17.2 (p = 0.008)], more initial abscesses [IA 35% vs. EA 13% (p = 0.0001)], more complications [IA 30% vs. EA 19%, (p = 0.013) and prolonged total length of stay [(LOS), p = 0.009]. Subgroup analysis of all patients revealed 80% of patients presented with ≤3 cm abscess and duration of symptoms (DOS) ≤5 days. Interval appendectomy patients with DOS ≤5 days and or ≤3 cm abscess on admission had no differences in clinical presentation. However, these patients had prolonged total LOS (IA 7.7 vs. EA 6.3 days, p = 0.01) and increased complications (IA 29% vs. EA 19%, p = 0.04). CONCLUSION: The majority of patients with complicated appendicitis in children present with small abscess (≤3 cm) and short symptom duration (≤5 days). This subset of patients might benefit from early appendectomy due to decreased LOS, resource utilization and reduced complications.

Perioperative Antibiotics Are Independent Predictors for Major Complications in Pediatric Patients Undergoing Gastrostomy Placement.

Introduction: Although rare, major complications after gastrostomy tube placement are a significant source of morbidity in children. The purpose of this study was to identify predictors of major complications in pediatric patients undergoing gastrostomy placement. Materials and Methods: Retrospective review of surgically placed gastrostomy tubes from 2010 to 2017 was performed. Data collected included demographics, outcomes, and major complications. We divided the patients into no complications (Group 1) and major complications (Group 2). Excluded were minor complications and percutaneous endoscopic gastrostomy procedures. Results: Of 123 patients, 51.5% were males and 52% infants. Group 1 had 112 patients (91%), whereas Group 2 had 11 patients (9%). Of Group 2 patients, 3 required prolonged nil per os/total parenteral nutrition and 8 surgical reinterventions. Laparoscopy in 110 patients (89%), open surgery in 10 patients (8%), and 3 conversions to open. There were no significant differences in demographics or preoperative characteristics (albumin and comorbidities). We identified surgical approach (open: 6.3% versus 27.3%, P = .014), operative time (58 versus 85 minutes, P = .04), and use of preoperative antibiotics (63% versus 92%, P = .004) as predictors of outcomes. However, on multivariate analysis lack of preoperative antibiotics (adjusted odds ratio [aOR], 14.82 [confidence interval: 2.60-84.34], P = .002), and open procedure (aOR, 6.14 [1.01-37.24], P = .049) were independent predictors of major complications. Conclusion: Most patients with major complications after gastrostomy tube placement require surgical reintervention. Lack of preoperative antibiotics and open procedures are independent predictive factors for major complication in patients undergoing gastrostomy tube placement.

Laparoscopic Excision of an Obstructing Soave Cuff in Hirschsprung's Disease.

BACKGROUND: The Soave pull-through for Hirschsprung's disease leaves a muscular cuff of aganglionosis surrounding the pull-through. In some patients, this cuff can extrinsically compress the pull-through, leading to chronic enterocolitis and failure to thrive. We describe a novel technique for managing the Soave cuff as an alternative to a complete redo pull-through. PROCEDURE: A laparoscopic excision of the intraperitoneal portion of the Soave cuff is performed, taking care to avoid injury to bladder, vas deferens, or vagina. The extraperitoneal portion of the cuff, adjacent to the bladder/vagina, is left in place. The excision is tailored to eliminate the obstruction and minimize injury to surrounding structures. Diverting colostomy is not necessary and patients are discharged the next day. RESULTS: Three patients successfully underwent excision without any operative complications and without the need for a colostomy. They had resolution of their chronic enterocolitis. CONCLUSION: In patients with an obstructing Soave cuff, a laparoscopic excision should be considered as a surgical option. We found that the procedure can be effective, with little morbidity.

Peritoneal Nodules in a Pediatric Patient with Benign Teratoma. A Case Report and Review of Literature.

BACKGROUND: Mature ovarian teratomas are common in children. These well differentiated tumors are typically confined to the ovary. In rare cases, they can rupture leading to granulomatous peritonitis that mimics carcinomatosis. Ovarian tumors with peritoneal/omental implants suggest malignant pathology with a different prognosis. CASE: A 15-year-old girl presented with 5 months of abdominal pain, and weight loss. Computed tomography (CT) imaging of the abdomen revealed a large mass filling the abdomen. Slightly elevated lactate dehydrogenase (LDH) and carcinoma antigen 125 (CA125). On laparotomy an ovarian tumor with peritoneal and omental implants was identified. Left salpingo-oophorectomy, omentectomy, and peritoneal washing were performed. Pathology revealed a benign cystic teratoma. SUMMARY AND CONCLUSION: Although ovarian teratomas are typically benign, they might mimic carcinomatosis. In patients with unexpected finding of peritoneal implants, histologic diagnosis is recommended before proceeding with a full oncologic ovarian resection.

Imaging before transfer to designated pediatric trauma centers exposes children to excess radiation.

BACKGROUND: Pediatric trauma patients transferred to pediatric trauma centers (PTCs) often have imaging at the originating hospital (OH). The increased use of computed tomography (CT) raises concerns about malignancy risk from ionizing radiation leading many PTCs to adopt radiation dose reduction strategies. We hypothesized that pediatric trauma patients are exposed to excess radiation from imaging before transfer. METHODS: A retrospective review of 1,383 scans was performed on all trauma patients with CT imaging before transfer to our Level I PTC from 2010 to 2014. Demographics, type of imaging, necessity for repeat imaging, appropriateness of imaging, and radiation dose delivered were recorded. Comparative radiation dosing was calculated using the dose-length product (DLP [expressed in mGy-cm]). All CT scans except for CT of the abdomen and pelvis and CT of the head were excluded for complete DLP data issues. Scans were considered clinically appropriate if they met Advanced Trauma Life Support (ATLS) recommendations (ATLS+) and not indicated if they did not meet ATLS criteria (ATLS-). Some scans were repeated because of technical issues. Median ΔDLP represents the difference in dose patients received at OH versus at PTC. RESULTS: A total of 673 patients were analyzed. Average age was 11 years, and 65.4% were male. Mean DLP at PTC was 54% lower for all analyzed scans compared with OH (p < 0.0001). DLP at PTC was 51% lower for CT of the abdomen and pelvis and 62% lower for CT of the head. Children received excess dose of 578.62 mGy-cm for scans at OH that were unnecessary. For ATLS+ imaging, children received a median excess of 444.42 mGy-cm of radiation at OH than they would have received had the scans been performed at PTCs using pediatric radiation reduction strategies. CONCLUSION: Pediatric trauma imaging performed at transferring institutions often does not adhere to ATLS recommendations and exceeds required ionizing radiation dosages. This study further confirms ATLS recommendations supporting prompt patient transfer without delay for imaging. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Management of H-type rectovestibular and rectovaginal fistulas.

INTRODUCTION: H-type rectovestibular or rectovaginal fistulas are rare entities in the spectrum of anorectal malformations seen in North America. Management options described in the literature have included perineal repair, anterior perineal anorectoplasty, vestibuloanal pull-through, and limited or formal posterior sagittal anorectoplasty, with a reported recurrence rate of 5% to 30%. We describe our approach and outcome in the management of these patients. METHODS: In a series of 1170 females with anorectal malformation, we cared for 8 patients who had an H-type rectovestibular or rectovaginal fistula and reviewed their clinical presentation, diagnosis, operative technique, and postoperative course. RESULTS: The patients' presenting symptoms included passage of stool per vagina (6), constipation (3), labial abscess (1), and recurrent urinary tract infection (1). There was associated anorectal stenosis in 3 patients. The remaining 5 patients had normal anal openings. Endoscopy was not helpful in locating the fistulas, but the fistulas were all demonstrated on direct inspection under anesthesia. The fistula was located in the vestibule (4), vagina (3), or labia (1). One patient had an associated presacral mass. Two patients had been operated on twice previously using a perineal repair and a protective colostomy and presented with third recurrences. In 5 cases, a posterior sagittal approach was used, placing sutures circumferentially around the fistulous opening on the rectal side, ligating the fistula, and pulling down a normal segment of rectum to be placed in front of the repaired vaginal wall. In our last 3 cases, we performed a transanal mobilization of the anterior rectal wall, leaving the perineal body intact. After our repairs, the patients have been followed up for 3 months to 15 years with a median of 15 months, and we have seen no recurrences. CONCLUSIONS: In addition to vaginal passage of stool, an H-type fistula should be suspected when there is a labial abscess in an infant, and an associated anal stenosis or presacral mass must be checked for. Direct inspection is the key, with a careful look in the vestibule, because endoscopy may miss the fistula. The essential technical point for repair is to get healthy anterior rectal wall to cover the area of fistula on the posterior vagina. A transanal approach, leaving the perineal body intact, is an excellent option for this repair.

Neoappendicostomy in the management of pediatric fecal incontinence.

PURPOSE: The Malone appendicostomy, for antegrade enemas, has improved the quality of life for many children with fecal incontinence. In patients whose appendix has been removed, a neo-appendix can be created. We describe our approach and experience with this procedure as an option for surgeons managing children with fecal incontinence. METHODS: The procedure involves creating a transverse flap of cecum that receives its blood supply by a transverse mesenteric branch. This flap is then tubularized around a feeding tube. The surrounding colon is plicated around the neo-appendix to prevent leakage of stool. The tip of the flap is then anastomosed to the deepest portion of the umbilicus. We reviewed our experience with this procedure, including results and complications. IRB approval was obtained. RESULTS: Eighty patients required a neo-appendicostomy. Sixty-six patients (82%) had an anorectal malformation, four had spina bifida, and ten had other diagnoses. The reasons for not having an appendix available included: "incidental" appendectomy (34, 42.5%), use of the appendix for a Mitrofanoff procedure (20, 25%), and Ladd's procedure (5, 6%). In fifteen patients (19%) we could find no appendix and assume that it was removed previously. Following neoappendicostomy, nine patients (11%) developed a stricture, and seven patients had leakage (9%). In 2004, we modified the appendiceal-umbilical anastomosis and among these patients, only one patient (3%) developed a stricture, compared with eight patients (18%) without the modification. All seven patients with leakage were within the first forty cases. No patient in the last forty cases had a leakage. CONCLUSIONS: In patients with the potential for fecal incontinence, the appendix should be preserved. In patients without an appendix, the neo-appendicostomy is a valuable tool for fecally incontinent patients. We have found that the V-V anastomosis had a reduced rate of stricture, and the rate of leakage seems to be related to surgical experience.

The appendix as a conduit for antegrade continence enemas in patients with anorectal malformations: lessons learned from 163 cases treated over 18 years.

INTRODUCTION: The antegrade continence enema (ACE) has been shown to be a safe and effective method for managing fecal incontinence in the pediatric population. The purpose of this study was to examine our experience with the ACE procedure using the appendix as a catheterizable conduit in children with anorectal malformations (ARMs). METHODS: We reviewed the charts of all patients who underwent an ACE procedure using the appendix as a catheterizable conduit between January 1992 and January 2010. Preoperative diagnosis (ARM type), operative details, functional outcomes, and postoperative complications were assessed. Technical modifications over time included selective cecoplication, implementation of the umbilical V-V appendicoplasty technique, and laparoscopy for cecal mobilization. RESULTS: Mean age was 9.9 ± 0.6 years, and 67% were male. The most common preoperative diagnosis was rectourethral fistula in boys (39%) and persistent cloaca in girls (61%). Forty-five complications occurred in 41 patients with an overall incidence of 25.6% (stricture, 18%; leakage, 6%; prolapse, 4%; intestinal obstruction, 0.6%). The incidence of stomal leakage was lower in patients when a cecoplication was performed (2.9% [4/138] vs 29.4% [5/17]; P < .01), and the incidence of stricture was lower in patients when the umbilical anastomosis was created using the V-V appendicoplasty technique (11% [11/100] vs 30% [18/60]; P < .01). Successful management of incontinence was reported by 96% of all patients. CONCLUSIONS: The ACE procedure using the umbilical V-V appendicoplasty provides an effective and cosmetically superior means for bowel management in children with ARMs. The rate of late complications is not insignificant however, and preventative strategies should focus on careful operative technique and ensuring compliance with catheterization protocols well past the initial postoperative period.