Adolescent Transition

Colin Baillie, Alder Hey Children's Hospital, Liverpool, United Kingdom

Consultant Paediatric Surgeon, Adolescent Transition

Background: Recent surgical trends have been towards increasing specialization. Paediatric surgeons have less sub-speciality expertise due to smaller numbers of patients. A recent study of paediatric surgical provision for children with inflammatory bowel disease identified a median experience of 0.9 J-pouch procedures per year of consultant practice {1}.

UK hospital infrastructure is tending to constrain “adult” surgical involvement in the care of children. The consequences of this are two-fold; the exclusion of children from the benefits of “super-specialization”, and the need for adolescent transition.

Transition may be an anxious time for the young adult who is “protected” by the holistic ethos of the paediatric environment. Barriers to successful transition include the surgeon’s concept of “duty of care” which does not sit well with handing over of responsibility at maturity {2}. It can be equally difficult for the adult surgeon to suddenly acquire responsibility for a surgical patient having had no opportunity for input into their earlier management. Studies suggest that patient satisfaction can be improved with a structured co-ordinated programme of transitional care {3}.

Congenital coloproctological conditions that might feature in a transitional programme include the spectrum of congenital anorectal malformations, and Hirschsprung’s disease (HSCR).
The management of anorectal malformations (ARM’s) was revolutionized by the Alberto Pena who described the posterior sagittal anorectoplasty (PSARP) {4}. The PSARP has proved extremely adaptable and has been applied to urogenital reconstruction in cloacal and urogenital sinus malformations by technical modifications such as total urogenital mobilization {5} and the anterior sagittal transrectal approach {6}. Pena described a new classification of ARM’s which assists appropriate neonatal management {7}. He championed the principles of an individually tailored bowel management programme {8}, in which continent appendicostomy (ACE procedure) has been an important adjunct {9}.
Swenson, Duhamel, and Soave procedures have long been employed to treat Hirschsprung’s disease. However, the transanal one-stage neonatal pull through represents a major advance and can be applied to 85% of children with left sided disease {10}.
Good quality long term outcome studies are lacking for these conditions. Operations for HSCR carry a 10% failure rate long term {11}. Causes include persisting sphincter achalasia, chronic enterocolitis and technical failure. Adolescents with poor prognosis ARM’s need life long bowel management due to sphincter weakness, and sadly those with good prognosis ARM’s may have poor continence as a result of a technically poor reconstruction or later development of megarectum.
Approximately 20% of children with inflammatory bowel disease require surgical intervention in childhood {12}. Children cope well with J-pouch ileoanal anastomosis {13}. A transitional care service for IBD is provided by 77% of UK paediatric centres {1}.
A group of children require surgical interventions for idiopathic constipation. Treatment is individualized and depends on whether hypomotility is pancolonic, or distal (with the frequent association of megarectum). The overall failure rate of appendicostomy ACE is 40% and of resectional surgery is 40%.

Conclusion: Transitional care is both topical and favoured by patients. The NHS will have to become less restrictive to facilitate appropriate transition of adolescent surgical patients.

References.

1. Smith NP, Ba’ath M, Perry D, et al. BAPS UK Inflammatory bowel disease surgical practice survey. J Pediatr Surg 2007;42:296-9
2. Fox A. Physicians as barriers to successful transitional care. Int J Adolesc Med Health 2002;14:3-7
3. Shaw KL, Southwood TR, McDonagh JE, et al. Young peoples satisfaction of transitional care in adolescent rheumatology in the UK. Child Care Health Dev 2007;33:368-79
4. de Vries P, Pena A. Posterior sagittal anorectoplasty. J Pediatr Surg 1982;17:638-43
5. Pena A. Total urogenital mobilization; an easier way to repair cloacas. J Pediatr Surg 1997;32:263-7
6. Mauermann J, Gonzales R, Franc-Guimond D, et al. The anterior sagittal transrectal approach for traumatic urethrovaginal fistula closure. J Urol 2004;171:1650-1
7. Pena A. Anorectal malformations. Semin Pediatr Surg 1995;4:35-47
8. Pena A, Guardino K, Tovilla JM, et al. Bowel management for fecal incontinence in patients with anorectal malformations. J Pediatr Surg 1998;33:133-7
9. Malone PS, Ransley PG, Kiely EM. Preliminary report: The antegrade continence enema. Lancet 1990;336:1217-8
10. Langer JC, Seifert M, Minkes RK. One stage Soave pull through for Hirschsprung’s disease; a comparison of the transanal and open approaches. J Pediatr Surg 2000;35:820-2
11. Baillie CT, Kenny, SE, Rintala RJ et al. Long term outcome and colonic motility following Duhamel’s procedure for Hirschsprung’s disease J Pediatr Surg 1999;34:325-9
12. Ba’ath ME, Mahmalat MW, Kapur P, et al. Surgical management of inflammatory bowel disease. Arch Dis Child 2007;42:296-9
13. Rintala RJ, Lindahl HG. Proctocolectomy and J-pouch ileoanal anastomosis in children. J Pediatr Surgery 2002;37:66-70