Assessment of quality of life in children with fecal escape before and after treatment with colon management

Os cuidados com as crianças com escape fecal vêm ganhando destaque crescente na cirurgia pediátrica visando melhorias no tratamento. Objetivo: Avaliar a qualidade de vida das crianças com escapes fecais antes e após o tratamento com o manejo de cólon. Metodologia: Pesquisa exploratória com levantamento de dados baseado em entrevista orientada pelo QQVCFCA e avaliação do grau de incontinência fecal baseado no score de Krickenbeck, ambos realizados em dois momentos, antes e após o tratamento. Para estabelecer significância estatística os dados foram submetidos ao teste t pareado de Student bicaudal com o objetivo de comparar os escores de QQVCFCA obtidos nos diferentes momentos. A fim de identificar quais aspectos do score de qualidade de vida foram mais impactados após o tratamento, as perguntas foram agrupadas em 4 domínios (estilo de vida, comportamento, depressão, constrangimento). Resultados: Foram analisados 90 pacientes, 65,56% do sexo masculino e 34,44% do sexo feminino. A idade inicial da entrevista variou entre 4 a 16 anos, média de 6,74 anos e mediana de 5 e, após o tratamento, entre 4,67 a 20 anos, média de 9,97 e mediana de 9. Segundo o diagnóstico 47,78% com constipação intestinal funcional, 24,44% com anomalia anorretal, 21,11% com doença de Hirschsprung e 6,67% com pacientes com intestino neurogênico secundário à lesões medulares. Quanto ao impacto do manejo de cólon no tratamento do escape fecal, em todos os domínios analisados houve melhora do score de qualidade de vida (p<0,01). Concluímos que crianças com escape fecal, independente de sua etiologia, tem no manejo de cólon um tratamento eficaz que resulta na continência social e em melhor qualidade de vida.Care for children with fecal incontinence has gained increasing prominence in pediatric surgery with a view to improving treatment. Objective: To evaluate the quality of life of children with fecal incontinence before and after treatment with bowel management. Methodology: Exploratory research with data collection based on an interview guided by the QQVCFCA and assessment of the degree of fecal incontinence based on the Krickenbeck score, both carried out at two moments, before and after treatment. To establish statistical significance, the data were subjected to the Student\'s paired t test with the aim of comparing the QQVCFCA scores obtained at different moments. In order to identify which aspects of the quality of life score were most impacted after treatment, the questions were separeted into 4 domains (lifestyle, behavior, depression, embarrassment). Results: 90 patients were analyzed, 65.56% male and 34.44% female. The initial age of the interview ranged from 4 to 16 years, mean of 6.74 years and median of 5 and, after treatment, between 4.67 to 20 years, mean of 9.97 and median of 9. According to the diagnosis 47 78% with functional constipation, 24.44% with anorectal malformation, 21.11% with Hirschsprung disease and 6.67% with spinal cord injuries. Regarding the impact of bowel management on the treatment of fecal incontinence, in all domains analyzed there was an improvement in the quality of life score (p<0.01). We conclude that children with fecal incontinence, regardless of their etiology, have an effective treatment in bowel management that results in social continence and a better quality of life

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030