Sacral nerve stimulation allows for decreased antegrade continence enema use in children with severe constipation.

BackgroundSacral nerve stimulation (SNS) can be beneficial for children with constipation, but no studies have focused on children with constipation severe enough to require antegrade continence enemas (ACEs). Our objective was to evaluate the efficacy of SNS in children with constipation treated with ACE.MethodsUsing a prospective patient registry, we identified patients <21years old who were receiving ACE prior to SNS placement. We compared ACE/laxative usage, PedsQL Gastrointestinal Symptom Scale (GSS), Fecal Incontinence Quality of Life Scale (FIQL), Fecal Incontinence Severity Index (FISI), and Vancouver Dysfunctional Elimination Syndrome Score (DES) at baseline and progressive follow-up time intervals.ResultsTwenty-two patients (55% male, median 12years) were included. Median ACE frequency decreased from 7 per week at baseline to 1 per week at 12months (p<0.0001). Ten children (45%) had their cecostomy/appendicostomy closed. Laxative use, GSS, FIQL, and DES did not change. FISI improved over the first 12months with statistical significance reached only at 6months (p=0.02). Six (27%) children experienced complications after SNS that required further surgery.ConclusionsIn children with severe constipation dependent on ACE, SNS led to a steady decrease in ACE usage with nearly half of patients receiving cecostomy/appendicostomy closure within 2years.Level of evidenceIV

Lymphocyte depression as a predictor of postoperative intraabdominal abscess after appendectomy in children

This study evaluated the efficacy of lymphopenia to predict postappendectomy intraabdominal abscess (IAA) in pediatric complex appendicitis. This single-center retrospective cohort study included appendectomy patients with complex appendicitis from 4/2012 to 10/2014. IAA was diagnosed based on imaging or undergoing a drainage procedure. Labs were used from the closest day prior to abscess diagnosis or day of discharge from index admission. Lymphocyte percentage was categorized based on age-specific cutoffs with lymphopenia defined as a low percentage. Comparisons were made using chi-square or Fisher exact tests for categorical variables and Mann–Whitney U-tests for continuous variables. Of 611 appendectomy patients with complicated appendicitis, 551 had WBC and differential. IAA was identified in 79 (12.9%) patients. There were no significant differences in demographics between IAA and non-IAA groups. Patients with IAA had higher rates of leukocytosis (44.3% versus 12.3%, p<0.001) and higher rates of age-based lymphopenia (84% vs. 46%, p<0.001). IAA was independently associated with leukocytosis (OR 3.65, p<0.001) and lymphopenia (OR 4.46, p<0.001). Patients with leukocytosis and lymphopenia had the highest abscess rate (36%), and those with normal labs had the lowest (3%, p<0.001). Lymphocyte depression is a useful adjunct to predict postoperative IAA in patients with complicated appendicitis. II

Sacral nerve stimulation allows for decreased antegrade continence enema use in children with severe constipation.

BackgroundSacral nerve stimulation (SNS) can be beneficial for children with constipation, but no studies have focused on children with constipation severe enough to require antegrade continence enemas (ACEs). Our objective was to evaluate the efficacy of SNS in children with constipation treated with ACE.MethodsUsing a prospective patient registry, we identified patients &lt;21years old who were receiving ACE prior to SNS placement. We compared ACE/laxative usage, PedsQL Gastrointestinal Symptom Scale (GSS), Fecal Incontinence Quality of Life Scale (FIQL), Fecal Incontinence Severity Index (FISI), and Vancouver Dysfunctional Elimination Syndrome Score (DES) at baseline and progressive follow-up time intervals.ResultsTwenty-two patients (55% male, median 12years) were included. Median ACE frequency decreased from 7 per week at baseline to 1 per week at 12months (p&lt;0.0001). Ten children (45%) had their cecostomy/appendicostomy closed. Laxative use, GSS, FIQL, and DES did not change. FISI improved over the first 12months with statistical significance reached only at 6months (p=0.02). Six (27%) children experienced complications after SNS that required further surgery.ConclusionsIn children with severe constipation dependent on ACE, SNS led to a steady decrease in ACE usage with nearly half of patients receiving cecostomy/appendicostomy closure within 2years.Level of evidenceIV

Hybrid computational phantoms of the 15-year male and female adolescent: Applications to CT organ dosimetry for patients of variable morphometry

Currently, two classes of the computational phantoms have been developed for dosimetry calculation: (1) stylized (or mathematical) and (2) voxel (or tomographic) phantoms describing human anatomy through mathematical surface equations and three-dimensional labeled voxel matrices, respectively. Mathematical surface equations in stylized phantoms provide flexibility in phantom design and alteration, but the resulting anatomical description is, in many cases, not very realistic. Voxel phantoms display far better anatomical realism, but they are limited in terms of their ability to alter organ shape, position, and depth, as well as body posture. A new class of computational phantoms—called hybrid phantoms—takes advantage of the best features of stylized and voxel phantoms—flexibility and anatomical realism, respectively. In the current study, hybrid computational phantoms representing reference 15-year male and female body anatomy and anthropometry are presented. For the male phantom, organ contours were extracted from the University of Florida (UF) 14-year series B male voxel phantom, while for the female phantom, original computed tomography (CT) data from two 14-year female patients were used. Polygon mesh models for the major organs and tissues were reconstructed for nonuniform rational B-spline (NURBS) surface modeling. The resulting NURBS∕polygon mesh models representing body contour and internal anatomy were matched to anthropometric data and reference organ mass data provided by the Centers for Disease Control and Prevention (CDC) and the International Commission on Radiation Protection (ICRP), respectively. Finally, two hybrid 15-year male and female phantoms were completed where a total of eight anthropometric data categories were matched to standard values within 4% and organ masses matched to ICRP data within 1% with the exception of total skin. To highlight the flexibility of the hybrid phantoms, 10th and 90th weight percentile 15-year male and female phantoms were further developed from the 50th percentile phantoms through adjustments in the body contour to match the total body masses given in CDC pediatric growth curves. The resulting six NURBS phantoms, male and female phantoms representing their 10th, 50th, and 90th weight percentiles, were used to investigate the influence of body fat distributions on internal organ doses following CT imaging. The phantoms were exposed to multislice chest and abdomen helical CT scans, and in-field organ absorbed doses were calculated. The results demonstrated that the use of traditional stylized phantoms yielded organ dose estimates that deviate from those given by the UF reference hybrid phantoms by up to a factor of 2. The study also showed that use of reference, or 50th percentile, phantoms to assess organ doses in underweight 15-year-old children would not lead to significant organ dose errors (typically less than 10%). However, more significant errors were noted (up to ∼30%) when reference phantoms are used to represent overweight children in CT imaging dosimetry. These errors are expected to only further increase as one considers CT organ doses in overweight and obese individuals of the adult patient population, thus emphasizing the advantages of patient-sculptable phantom technology

Screening practices and associated anomalies in infants with anorectal malformations: Results from the Midwest Pediatric Surgery Consortium

© 2018 Elsevier Inc. Background: This study evaluates screening practices and the incidence of associated anomalies in infants with anorectal malformations (ARM). Methods: We performed a multi-institutional retrospective cohort study of children born between 2007 and 2011 who underwent surgery for ARM at 10 children\u27s hospitals. ARM type was classified based on the location of the distal rectum, and all screening studies were reviewed. Results: Among 506 patients, the most common ARM subtypes were perineal fistula (40.7%), no fistula (11.5%), and vestibular fistula (10.1%). At least 1 screening test was performed in 96.6% of patients, and 11.3% of patients underwent all. The proportion of patients with ≥ 1 abnormal finding on any screening test varied by type of ARM (p \u3c 0.001). Screening rates varied from 15.2% for limb anomalies to 89.7% for renal anomalies. The most commonly identified anomalies by screening category were: spinal: tethered cord (20.6%); vertebral: sacral dysplasia/hemisacrum (17.8%); cardiac: patent foramen ovale (58.0%); renal: hydronephrosis (22.7%); limb: absent radius (7.9%). Conclusion: Screening practices and the incidence of associated anomalies varied by type of ARM. The rate of identifying at least one associated anomaly was high across all ARM subtypes. Screening for associated anomalies should be considered standard of care for all ARM patients. Type of study: Multi-institutional retrospective cohort study. Level of evidence: II

Can Fecal Continence be Predicted in Patients Born with Anorectal Malformations?

Purpose The purpose of this study was to identify factors associated with attaining fecal continence in children with anorectal malformations (ARM). Methods We performed a multi-institutional cohort study of children born with ARM in 2007–2011 who had spinal and sacral imaging. Questions from the Baylor Social Continence Scale were used to assess fecal continence at the age of ≥ 4 years. Factors present at birth that predicted continence were identified using multivariable logistic regression. Results Among 144 ARM patients with a median age of 7 years (IQR 6–8), 58 (40%) were continent. The rate of fecal continence varied by ARM subtype (p = 0.002) with the highest rate of continence in patients with perineal fistula (60%). Spinal anomalies and the lateral sacral ratio were not associated with continence. On multivariable analysis, patients with less severe ARM subtypes (perineal fistula, recto-bulbar fistula, recto-vestibular fistula, no fistula, rectal stenosis) were more likely to be continent (OR = 7.4, p = 0.001). Conclusion Type of ARM was the only factor that predicted fecal continence in children with ARM. The high degree of incontinence, even in the least severe subtypes, highlights that predicting fecal continence is difficult at birth and supports the need for long-term follow-up and bowel management programs for children with ARM