| Background The incidence of postoperative constipation and defecation dysfunction in patients with anorectal malformation(ARM)remains high,affecting the quality of life.There are few studies on the factors associated with postoperative constipation in ARM,and the lack of quantitative analysis of risk factors makes it difficult to provide pediatric surgeons and parents with a reference for the probability of postoperative constipation.The present study aims to explore the risk factors and establish a prediction model for postoperative constipation in ARM patients to provide early bowel management for children at high risk of constipation.Methods We retrospectively reviewed clinical data of children with ARM who underwent anorectoplasty at our institution between July 2008 and December 2019.A total of 456 children were included in the analysis,and they were randomly divided into the modeling and validation sets with a ratio of 3:1.Based on the univariate and multivariate Logistics regression analysis of the clinical data in constipation and non-constipation groups in the modeling set,the independent influencing factors of postoperative constipation were screened,and the nomogram model was made.The performance of the nomogram model was evaluated by Receiver Operating Characteristic(ROC),Hosmer-Lemeshow test,and calibration plot.Decision curve analysis was used to evaluate the benefits of the models in clinical use.Results The incidence of constipation in this study was 24.6%(112/456).In the modeling set,the results of univariate analysis and binary Logistic regression showed that high-(OR:11.863,95%CI 3.246-43.345)and middle-type ARM(OR:6.937,95%CI 1.978-24.333),rectal dilatation(OR:2.110,95%CI 1.198-3.715),assessment age<6.5 years old(OR:2.548,95%CI 1.382-4.699),and abnormal development of ganglion cells(OR:1.844,95%CI 1.028-3.305)were independent risk factors for postoperative constipation.Based on the above predictors,a nomogram prediction model was established.In the modeling set,the AUC of the prediction model was 0.788(95%CI 0.735-0.841),and the sensitivity and specificity were 73.6%and 71.8%,respectively.In the validating sets,the AUC of the model was 0.748(95%CI 0.643-0.852),indicating good discrimination.The calibration plots fitted well in both sets suggesting the model has good predictive efficacy for screening children at high risk of constipation.The Hosmer-Lemeshow test suggests the model has good goodness of fit.Decision curve analysis showed the nomogram prediction model had important clinical value for the prediction of constipation.Conclusions ARM classification,rectal dilatation,age at assessment,and development of ganglion cells are independent risk factors for postoperative constipation in ARM patients.The nomogram prediction model established for constipation has good predictive efficacy,providing a convenient clinical prediction tool for pediatric surgeons.Background Laparoscopic-assisted anorectoplasty(LAARP)has become a routine procedure for high and intermediate anorectal malformations(ARM).However,the incidence of rectal prolapse after LAARP is high,which affects bowel function and quality of life.There is a lack of targeted research on etiology and influencing factors of rectal prolapse after LAARP,which cannot guide clinical strategies for individualized treatment plans to prevent rectal prolapse.The present study aims to explore the risk factors and establish a prediction model for rectal prolapse after LAARP in ARM patients,which has important clinical significance.Methods We retrospectively reviewed clinical data of children with ARM who underwent LAARP at our institution between July 2008 and December 2019.A total of 333 children were included in the analysis,and they were randomly divided into the modeling and validation sets with a ratio of 3:1.Based on the univariate and multivariate Logistics regression analysis of the clinical data in prolapse and non-prolapse groups in the modeling set,the independent influencing factors of rectal prolapse were screened,and the nomogram model was made.The performance of the nomogram model was evaluated by Receiver Operating Characteristic(ROC),Hosmer-Lemeshow test,and calibration plot.Decision curve analysis was used to evaluate the benefits of the model in clinical use.Results The incidence of rectal prolapse in this study was 15.3%(51/333).In the modeling set,the results of univariate analysis and binary Logistic regression showed that transverse colostomy had a higher risk of rectal prolapse than descending/sigmoid colostomy(OR:3.386,95%CI 1.324-8.657)and without colostomy(OR:9.512,95%CI 1.231-73.497).In addition,associated sacrovertebral defects(OR:2.624,95%CI 1.229-5.602),associated urologic malformations(OR:2.356,95%CI 1.102-5.037),and anorectoplasty performed with colostomy closure(OR:3.357,95%CI 1.165-9.675)were also independent risk factors for rectal prolapse.Based on the above predictors,a nomogram prediction model was established.In the modeling set,the AUC of the prediction model was 0.784(95%CI 0.704-0.865),and the sensitivity and specificity were 81.1%and 71.4%,respectively.In the validating sets,the AUC of the model was 0.812(95%CI 0.709-0.914),indicating good discrimination.The calibration plots fitted well in both sets suggesting the model has good predictive efficacy for screening children at high risk of rectal prolapse.The HosmerLemeshow test suggests the model has good goodness of fit.Decision curve analysis showed the nomogram prediction model had important clinical value for the prediction of rectal prolapse.Conclusions Type of colostomy,associated sacrovertebral defects,associated urologic malformations,and anorectoplasty performed with colostomy closure are independent risk factors for rectal prolapse after LAARP in ARM patients.It is recommended to avoid transverse colostomy if possible.The nomogram prediction model established for rectal prolapse has good predictive efficacy which can provide a convenient clinical prediction tool for pediatric surgeons.Background Currently,the three-staged procedure is the mainstay for the high and intermediate anorectal malformations(ARM).However,early reconstruction of the anorectal continuity is essential for establishing brain-defecation reflexes and training perineal musculature to improve long-term fecal continence.Some drawbacks include urinary tract contamination,stoma care burden,multiple periprocedural risks,and hypertrophy rectum because of a period of delay before definitive repair.The laparoscopicassisted anorectoplasty(LAARP)procedure has its unique advantages and has achieved promising short-term results in neonates with rectourethral fistula.Whether the functional outcome of a one-stage LAARP procedure is better compared with conventional staged LAARP remains controversial.The present study aims to report the medium-term functional results of the one-stage LAARP procedure and compare them with the staged LAARP.Methods This study included 242 boys who underwent LAARP between June 2013 and December 2019 at the Capital Institute of Pediatrics.Forty-five neonatal patients successfully underwent the one-stage LAARP,and the remaining 197 patients received staged procedures.A propensity score matching(PSM)was performed to minimize the effects of confounding variables related to differences in the two groups of patients.The complications and bowel function were compared between the two groups after 1:1 PSM.Results Before matching,age at assessment and ARM classification were significantly different between the two groups(P<0.05).After PSM,42 patients were included in each of the two groups,and the patients were well balanced.The median postoperative hospital stay in the one-stage was longer than that in the staged group(12.0 vs.8.5 days,P<0.001).The overall occurrence of postoperative complications in the one-stage group was significantly lower than in the staged group(7.1%vs.26.2%,P=0.019).A total of 11 cases(26.2%)in the staging group experienced complications,including 3 stoma-related complications,2 anastomotic infections,1 postoperative intestinal obstruction,and 5 cases of rectal prolapse.In contrast,a total of 3 cases(7.1%)in the one-stage group experienced complications,including 2 cases of intestinal obstruction and 1 case of rectal prolapse.Thirty-three patients in the one-stage group and 38 patients in the staged group,respectively,were successfully follow-up.At the time of bowel function assessment,the mean ages of the two groups were 4.94 years and 5.01 years,respectively.The mean value of BFS was higher in the one-stage group(15.5±2.59 vs.14.6±2.77),but this was not statistically significant(P=0.163).After medical management,the proportion of voluntary bowel movements was higher in the one-stage group than in the staged group(33.4%vs.23.7%).The proportion of patients with constipation and overflow pseudo-incontinence was lower in the one-stage group than in the staged group(30.3%vs.39.5%),but this was not statistically significant(P=0.307).Conclusions One-stage LAARP is safe and feasible for neonates ARMs with rectourethral fistula.Compared with staged LAARP,one-stage LAARP has fewer complications and comparable functional outcomes.Preoperative voiding cystourethrogram,pelvic MRI,and invertogram to determine the location of the recto-urethral fistula;intraoperative decompressing of the dilated bowels to create adequate working space and provide good exposure;postoperative placement of a rectal tube to prevent anastomotic leak are the keys to success in neonatal one-stage LAARP surgery. |
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