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Background: Hirschsprung associated enterocolitis (HAEC) is a challenging problem in a subset of children with Hirschsprung disease (HD). In refractory cases, fecal diversion may be required. The aim of this study was to characterize patients who require fecal diversion for HAEC management and examine their long-term outcomes., Methods: A retrospective review of prospectively collected data within the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC) registry was performed. All children with a history of a corrective procedure for HD and documented post-operative HAEC were included. Our primary outcome was diversion to manage HAEC after pull-through and secondary outcomes included incidence of recurrent HAEC, fecal continence following ostomy closure, and bowel management needs at last follow-up., Results: 951 patients were identified with a history of HD and 852 had undergone pull-through. 339/852 (39.8 %) had documented HAEC and 75/339 (22.1 %) required an ostomy, 54 (72 %) of which underwent reversal at a median of 239.5 days. After reversal, 10/54 (18.5 %) required repeat diversion for recurrent HAEC. 30/75 (40 %) had their pull-through revised. Median age at last follow-up was 5.3 [3.4, 9] years. At time of last follow-up, 40.3 % were toilet-trained for stool and 42.9 % required long term enema-based therapy., Conclusion: Fecal diversion for refractory HAEC was common in our study. Slightly more than half of the patients underwent successful closure of their stoma during over 4.5 years of follow-up, while less than half were toilet-trained for stool at their last visit. These children may represent a unique cohort that warrants further investigation., Level of Evidence: Level VI., Competing Interests: Conflict of interest The authors of this paper have no disclosures or conflicts of interest to report relevant to this project., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Although legged robots have demonstrated effective mobility in some natural settings, as robot size decreases, obstacles in their environment become challenging to overcome. Small arthropods scale obstacles many times their size through jumps powered by mechanisms that overcome speed and power limitations of muscle alone. The motivation for this study was to explore the marriage of impulsive (jumping) and nonimpulsive (cyclic legged ambulation) behaviors in a centimeter-scale robot. Here, jumping is achieved by striking the ground with a bioinspired appendage connected to a parallel linkage. As the linkage configuration passes through the singularity, a torque reversal occurs whereby elastic energy slowly stored by force-dense velocity-limited shape memory alloy actuators is rapidly released. A passively driven elastic hinge is introduced in the striking arm to mediate ground contact forces and direct jumping. High-speed video recording of the 14-millisecond launch phase reveals previously undocumented takeoff dynamics closely resembling those of springtails. A dynamic model was derived, and an experimentally validated simulation was used to optimize the design of key components. The 2.2-gram, 6.1-centimeter-long mechanism achieved a maximum horizontal jumping distance of 1.4 meters (23 body lengths), surpassing that of similarly sized insects. The mechanism was integrated with an agile quadrupedal microrobot with leg articulation suitable to achieve the ideal jumping posture. The platform demonstrated repeatable directional takeoffs and upright landings, enabling complex maneuvers to overcome obstacles and gaps. Last, we used this bioinspired robot to offer reflection on hypotheses related to springtail jumping behavior.

Background In patients with Hirschsprung disease (HD), pelvic floor physical therapy (PFPT) is recommended for persistent incontinence or constipation refractory to other treatment, but there are no studies on utilization of PFPT. We aimed to assess clinical and sociodemographic factors associated with successful establishment with PFPT and outcomes following PFPT. Methods We performed a single-institution, retrospective chart review of patients with HD referred to PFPT between 2020 - 2023, involving both exercise and biofeedback. Data were collected on clinical factors, sociodemographics, and symptoms before and after PFPT. Those who "saw PFPT", defined as at least one in-person appointment, were compared to those who did not see PFPT; symptomst were also compared. A p-value of 0.05 was considered significant. Results There were 83 patients, of which 37 (44.6%) saw PFPT. There were no differences in age, transition zone, prior interventions, or symptoms. Half of patients who saw PFPT only completed an initial visit; one fifth completed the series. Most common reason for failure to see PFPT was scheduling issues. Patients who failed to see PFPT had financial stressors (42.5% vs 16.1%, p=0.02) and required formal support systems (28.2% vs 3.3%, p=0.02). In patients seeing PFPT, incontinence significantly improved (81.1% before vs 40.5% after, p=0.001). Conclusion While PFPT is recommended in children with HD, those with financial stressors or scheduling issues may have barriers to access. However, those who see PFPT have improved symptoms. This suggests a need for improved accessibility of pediatric PFPT to children with HD, such as integration of PFPT into colorectal clinics., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Background: Functional outcomes following reconstruction of anorectal malformations are important to assess and optimize. Patients with anorectal malformations of all severity need to be followed in a multidisciplinary fashion long-term to adequately assess these outcomes and maximize success., Methods: This multidisciplinary review is a highlight of the panel presentation at the American Academy of Pediatrics Section on Surgery meeting., Results: This multidisciplinary review includes recommendations for the monitoring and management of children with anorectal malformations, including both functional stooling and urologic outcomes., Conclusion: Multidisciplinary longitudinal care is required to achieve optimal functional outcomes for children with anorectal malformations., Competing Interests: Conflicts of interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2025 Elsevier Inc. All rights reserved.)

Refractory constipation (RC) in pediatric patients should be recognized as a distinct condition with long-term impacts on patient and family quality of life. RC requires a more targeted diagnostic evaluation and complex management strategy that may involve management by pediatric neurogastroenterology and motility specialists and multidisciplinary teams including surgeons. Currently, there is a lack of a clear definition, evaluation, and management strategies for RC. This is the first North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition position paper to address pediatric RC regarding its definition, evaluation, and management., (© 2024 European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.)

Objective: Patients with anorectal malformations (ARMs) may have concurrent gynecologic abnormalities. As patients grow, they typically transition from pediatric subspeciality care and seek adult obstetrics and gynecology (OB/GYN)-related services. We aimed to assess adult OB/GYN physicians' knowledge, competency, and comfort regarding meeting the sexual and reproductive health care needs of patients with ARMs., Methods: We performed a cross-sectional observational survey-based study of graduates from a single academic OB/GYN residency program from 2013 to 2022. Physicians were surveyed on experience, comfort, and challenges with caring for patients with ARMs and given a knowledge assessment. Descriptive and comparative statistics between those who did and did not complete a Pediatric and Adolescent Gynecology (PAG) rotation were generated., Results: There were 59 respondents (53.6%). Fewer than half (39.0%) reported caring for a patient with an ARM, an appendicovesicostomy (12.3%), or an appendicostomy (5.4%). Most felt uncomfortable (80.4%) or felt they lacked competence in caring for these patients (81.8%). Most (64.3%) felt that ARMs should be discussed in residency. Only 1 physician (1.7%) answered all questions in the knowledge assessment correctly; 33.9% did not answer any question correctly. On subgroup analysis, more physicians who had completed a pediatric and adolescent gynecology rotation recalled learning about ARMs (83.3% vs 51.9%, P = .03); however, there were no differences in experience, comfort, competence, or willingness to learn., Conclusion: OB/GYN providers report a lack of knowledge and comfort in caring for patients with ARMs. Development of a standardized OB/GYN residency curriculum and education for practicing OB/GYN physicians is necessary to allow access to knowledgeable sexual and reproductive health for this patient population., Competing Interests: Conflicts of Interest The authors report no conflicts of interest., (Copyright © 2024. Published by Elsevier Inc.)

Objectives: Colonic manometry catheter placement can be performed by colonoscopy or fluoroscopy. Our objective was to compare outcomes of colonoscopic to fluoroscopic catheter placement in children based on the extent of colon study and the likelihood of catheter displacement., Methods: Colonic manometry studies performed between May 2015 and May 2022 were reviewed. All studies with catheter placement per rectum were included. Data on patient demographics, medical and surgical history, and information on catheter placement (type of catheter, placement technique, position, and displacement) were recorded., Results: We reviewed 555 studies and included 482 studies performed on 453 children (51% female, median age 10 years, interquartile range: 7-14 years). The catheter was placed during colonoscopy in 274 studies and using fluoroscopy in 208 studies. Children with colonoscopic placement were significantly older (median age 11 vs. 8 years, p < 0.001), more commonly male (55% vs. 41%, p = 0.003), and more commonly had functional constipation (85% vs. 69%, p < 0.001). Children with fluoroscopic placement more often had pediatric intestinal pseudo-obstruction (10% vs. 1%, p < 0.001), a diverting ostomy (21% vs. 7%, p < 0.001), and a cecostomy (10% vs. 4%, p = 0.023). A successful catheter placement (reaching ascending colon) was significantly more common using colonoscopy (49% vs. 23%, p < 0.001). There were no differences in frequency or extent of catheter displacement between colonoscopic and fluoroscopic placement., Conclusions: Colonoscopic placement was superior to fluoroscopic placement in terms of the extent of the colon studied with no differences in frequency of catheter displacement. Colonoscopic placement should be the preferred method in most children with refractory constipation., (© 2024 The Author(s). Journal of Pediatric Gastroenterology and Nutrition published by Wiley Periodicals LLC on behalf of European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.)

Background: Individually collected social determinants of health (SDOH) have been associated with negative outcomes in children with anorectal malformations (ARMs). Our aim was to assess whether the Child Opportunity Index (COI) is associated with bowel management strategy and fecal cleanliness in patients with ARM managed at specialized pediatric colorectal centers. We hypothesized that children from low COI would have lower rates of cleanliness., Methods: A multi-institutional retrospective review evaluated children ≥4 years old with ARM treated at centers participating in the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC), excluding patients with ostomies. The primary exposure was COI, obtained by ZIP code. The primary outcome was fecal cleanliness, defined as ≤1 weekly stool accident. Additional variables evaluated included demographics, ARM severity, bowel management type, medical comorbidities, and complications in those undergoing antegrade continence enema procedures. COI groups were compared for trend (p-value ≤0.05 as significant)., Results: The cohort included 550 patients, most (75.1%) residing in moderate, high, or very high opportunity areas. There were no differences in ARM severity between COI groups. Stratified by age, there were no differences in fecal cleanliness (p = 0.788) or bowel management strategy (p = 0.224) by COI. There were few overall complications from ACE placement (12.3%), but ACE complications were more common in children from low-opportunity areas (22.2% vs 2.9%; p = 0.01)., Conclusion: Contrary to hypothesized, children with anorectal malformations managed at tertiary institutions within PCPLC do not differ by COI in bowel management strategy or fecal cleanliness outcome. Further investigation into individual disparities may be more important in these patients., Level of Evidence: III = retrospective comparative study., Competing Interests: Conflicts of interest The authors have no conflicts of interest to disclose., (Copyright © 2024. Published by Elsevier Inc.)

Aim: A novel modification of the cutback procedure, a posterior rectal advancement anoplasty (PRAA) for select male patients with an anorectal malformation and a rectoperineal fistula was recently described which incised only within the limits of the sphincteric ellipse and eliminated an anterior rectal dissection, thus avoiding any possibility of a urethral injury. This report provides longer term postoperative outcomes after PRAA. Method A retrospective, single institution study was performed examining male patients with a rectoperineal fistula between 1/2020-12/2023. PRAA was done only if the rectoperineal fistula was located within the anterior extent of the sphincteric ellipse, which was true for all patients encountered during this study period. We assessed post-operative outcomes, length of stay, time to first feeding, and early stooling patterns. Results Eighteen patients underwent PRAA at a median age of 5.4 months (range 1 day-8 months) with median follow up of fourteen months (range 4-40). Seven patients (39%) were repaired within the first month of life. Thirteen (72%) were repaired primarily and five (28%) had a diverting ostomy placed before referral. There were no instances of wound dehiscence, rectal prolapse, or urethral injury. Two (11%) patients developed an anal stricture requiring dilation or Heineke-Mikulicz anoplasty. All patients resumed feeds on post operative day one. Median discharge was on post operative day one (range 1-6). Fifteen (83%) were utilizing laxatives at their most recent follow up. Conclusions The PRAA avoids any potential urethral injury or perineal dehiscence, has a low rate of anal stenosis (11%), and appears to be applicable to all male patients with a rectoperineal fistula. The technique allows for early return to diet and discharge and can be safely done in the neonatal period or in a delayed fashion without the need for a stoma., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Background: The Heineke-Mikulicz anoplasty (HMA) is a technique for addressing skin-level postoperative strictures following posterior sagittal anorectoplasty (PSARP) and posterior sagittal anorectovaginourethroplasty (PSARVUP). We aimed to evaluate the long-term outcomes with HMA as a treatment for postoperative anal strictures., Methods: A retrospective review was conducted for patients with a history of ARM who underwent HMA for skin-level anal strictures. Data were collected regarding indication for HMA, most recent anorectoplasty preceding HMA (primary or redo), timing of HMA, extent of stricturoplasty, change in caliber of anus, and postoperative outcomes. Descriptive statistical analysis was performed., Results: From 2015 to 2024, 138 patients with history of ARM underwent HMA. Median age at time of HMA was 4 years [IQR 2-6] with median follow up time of 3.0 years [IQR 1.0-4.0]. HMA was performed after primary PSARP or PSARVUP in 29 % of patients and after redo surgery in 61.6 %. The minimum time between index operation and initial HMA was 2 months and the median was 5 months [IQR 3-24]. 14.5 % of patients required repeat HMA. The median time between index operation and repeat HMA was 24 months (IQR 12-39). There was a significant trend between number of quadrants where HMA was performed and need for repeat HMA., Conclusion: HMA is a safe and durable procedure that can treat skin-level postoperative anal strictures in most patients following PSARP and PSARVUP. Patients can frequently be managed with a one-time HMA. HMA should be considered as an alternative to dilation for skin-level anal strictures, especially in an older patient after redo surgery., (Copyright © 2025 Elsevier Inc. All rights reserved.)

Many aquatic organisms utilize suction-based organs to adhere to diverse substrates in unpredictable environments. For multiple fish species, these adhesive discs include a softer disc margin consisting of surface structures called papillae, which stabilize and seal on variable substrates. The size, arrangement, and density of these papillae are quite diverse among different species, generating complex disc patterns produced by these structures. Considering papillae arrangements in three fish species, the Northern Clingfish (Gobiesox maeandricus), Tidepool Snailfish (Liparis florae), and Chilean Clingfish (Sicyases sanguineus), we fabricated physical disc models that tested relevant surface pattern parameters under shear loading conditions. Parameters of interest included the area of papillae-like structures, the spacing between adjacent structures (channel spacing), and the percent coverage of elements relative to the total disc area. To create our models, a soft silicone elastomer was added to a stiff circular suction cup, which was then "stamped" using a laser-etched and thermoformed mold base to create the desired surface patterning. Discs were tested using a robotic arm equipped with a force sensor, which sheared them across smooth and rough surfaces at a fixed speed and distance. The arm was also used to vary the initial compression to test performance under both suction-dominant and friction-dominant preloads. For our designs, patterns with smaller papillae-like structures and channel spacing often produced higher peak forces than those with larger features. However, the design that withstood the highest shear load featured an intermediate pad size and channel spacing, potentially highlighting a balance between overall surface area and fluid channeling. Additionally, discs with surface patterns often outperformed the control discs (no pattern) on both smooth and rough surfaces, but performance was highly dependent on preload, with patterned discs exhibiting benefits with the higher "friction-dominant" preloads., Competing Interests: Declarations. Competing Interests: Author Robert J. Wood holds stock in Fleet Robotics, Inc., a marine robotics company focused on robotic anti-biofouling., (© 2024. The Author(s).)

Objective: We aimed to study the impact of anorectal malformation (ARM) type and sacral ratio on continence outcomes in children. We secondarily aimed to compare continence outcomes by age group and determine quality of life (QoL) with different bowel regimens., Summary Background Data: Children with ARM experience dysfunctional stooling into adulthood. Little is known about how ARM type, sacral ratio, age, and bowel regimen affect continence and QoL., Methods: We administered five validated survey measures on stooling habits and QoL to children aged 2-19 with ARM at two tertiary hospitals. Sacral ratio as a determinant of sacral hypodevelopment was defined as normal (≥0.7), moderate (0.4-0.0.69), or severe (≤0.39). Children not on an enema program were compared to those on an enema program to identify factors associated with achieving voluntary bowel movements defined as continence. All children were compared to identify factors associated with QoL., Results: Of 910 patients, half (52.8%) had mild sacral hypodevelopment. In patients not receiving enemas managed solely at study hospitals, most were continent (69.2%). There were no differences in continence demonstrated by sacral ratio; 79.4% of those who were continent had normal/moderate sacral hypodevelopment and mild ARM.Continence improved with age (50% ≤6 y old, 69.8% 6-12 y old, 82.1% >12 y old; P<0.001). Those on enemas and soiling had a QoL 19.6 points lower than those soiling on laxatives, and 20.7 points lower than those who were clean on enemas or continent with voluntary bowel movements without the need for enemas., Conclusions: In patients on laxatives the type of malformation, but not sacral ratio, is associated with continence in patients with ARM. Continence improves with age; those on enemas with soiling have a worse QoL., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Optimizing mechanical adhesion to specific human tissue types is a field of research that has gained increasing attention over the past two decades due to its utility for diagnostics, therapeutics, and surgical device design. This is especially relevent for medical devices, which could benefit from the presence of attachment mechanisms in order to better target-specific regions of the gastrointestinal (GI) tract or other soft tissues for sensing, sample collection, and drug release. In this work, and inspired by the tissue anchoring adaptations found in diverse parasitic taxa, we present a design and manufacturing platform for the production of a nonintuitive bioinspired millimeter-scale articulated attachment mechanism using laminate fabrication techniques. The functional design closely mimics the geometry and motions of curved hooks employed by some species of tapeworms to attach to their host's intestinal walls. Here, we show the feasibility of such a mechanism both in terms of attachment capabilities and manufacturability. Successful attachment of a prototype to tissue-simulating synthetic medical hydrogels is demonstrated with an adhesion force limited only by the ultimate strength of the tissue. These results demonstrate the efficacy of parasite-inspired deployable designs as an alternative to, or complement to, existing tissue attachment mechanisms. We also describe the design and manufacturing process workflow and provide insights for scaling the design for mass-production., (© The Author(s) 2024. Published by Oxford University Press on behalf of National Academy of Sciences.)

Introduction:  Children with anorectal malformations (ARMs) benefit from bowel management programs (BMPs) to manage constipation or fecal incontinence. We aimed to understand the role of social determinants of health (SDOH) in outcomes following BMPs in this population., Materials and Methods:  A single-institution, institutional review board (IRB) approved, retrospective review was performed in children with ARM who underwent BMP from 2014 to 2021. Clinical, surgical, and SDOH data were collected. Children were stratified as clean or not clean per the Rome IV criteria at the completion of BMP. Descriptive statistics were computed. Categorical variables were analyzed via Fisher's exact tests and continuous variables with Mood's median tests., Results:  In total, 239 patients who underwent BMP were identified; their median age was 6.62 years (interquartile range [IQR]: 4.78-9.83). Of these, 81 (34%) were not clean after completing BMP. Children with prior history of antegrade enema procedures had a higher rate of failure. Children who held public insurance, lived within driving distance, had unmarried parents, lived with extended family, and lacked formal support systems had a significant association with BMP failure ( p  < 0.05 for all). Type of ARM, age at repair, type of repair, age at BMP, and type of BMP regimen were not significantly associated with failure., Conclusions:  There is a significant correlation of failure of BMPs with several SDOH elements in patients with ARM. Attention to SDOH may help identify high-risk patients in whom additional care may lead improved outcomes following BMP., Competing Interests: None declared., (Thieme. All rights reserved.)

To navigate complex terrains, insects use diverse tarsal structures (adhesive pads, claws, spines) to reliably attach to and locomote across substrates. This includes surfaces of variable roughness and inclination, which often require reliable transitions from ambulatory to scansorial locomotion. Using bioinspired physical models as a means for comparative research, our study specifically focused on the diversity of tarsal spines, which facilitate locomotion via frictional engagement and shear force generation. For spine designs, we took inspiration from ground beetles (family: Carabidae), which is a largely terrestrial group known for their quick locomotion. Evaluating four different species, we found that the hind legs host linear rows of rigid spines along the entire tarsus. By taking morphometric measurements of the spines, we highlighted parameters of interest (e.g., spine angle and aspect ratio) in order to test their relationship to shear forces sustained during terrain interactions. We systematically evaluated these parameters using spines cut from stainless steel shim attached to a small acrylic sled loaded with various weights. The sled was placed on 3D-printed models of rough terrain, randomly generated using fractal Brownian motion, while a motorized pulley system applied force to the spines. A force sensor measured the reaction force on the terrain, recording shear force before failure occurred. Initial shear tests highlighted the importance of spine angle, with bioinspired anisotropic designs producing higher shear forces. Using these data, we placed the best (50° angle) and worst (90° angle) performing spines on the legs of our insect-scale ambulatory robot physical model. We then tested the robot on various surfaces at 0°, 10°, and 20° inclines, seeing similar success with the more bioinspired spines., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Society for Integrative and Comparative Biology.)

Objectives: Children with functional constipation (FC) and autism spectrum disorder (ASD) often face sensory and behavioral conditions that prevent giving oral medical therapy to improve constipation and incontinence. We aimed to assess whether children with ASD and FC who had difficulty in taking oral medications could benefit from gastrostomy tube (GT) placement., Methods: A single-institution retrospective review was performed in children diagnosed with ASD and FC from 2020 to 2023. Children were considered candidates for GT if they suffered from constipation that adversely affected daily function and refused adequate oral medical therapy. Data were collected on ASD severity and FC symptoms before GT and after GT placement., Results: There were nine patients who underwent GT placement. Median age was 7.4 years (interquartile range [IQR]: 4.8-9.7). Of the five with available ASD evaluations, four had extremely low intelligence quotient and extremely low adaptive skills; only one child of the nine was verbal. Before GT placement, most patients had Bristol 1 or 2 consistency stool (66.7%); following placement, most had Bristol 5 or 6 consistency stool (66.7%). Seven children strained with bowel movements before GT; only one child strained after GT. There were no tube dislodgements or site infections. Gastrointestinal quality of life scores improved for both constipation (+38.5, IQR: 27.5-54.3) and medication administration (+31.5, IQR: 0.0-75.0)., Conclusions: GT placement may be a viable option in children with FC and ASD with minimal complications, improvement in constipation, and improvement in quality of life. Further prospective study will ensure generalizability of these results., Competing Interests: The authors declare no conflicts of interest., (© 2024 The Author(s). JPGN Reports published by Wiley Periodicals LLC on behalf of The European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.)

Background: Children with total colonic Hirschsprung disease (TCHD) are a unique group of patients with pre- and postoperative management challenges. This review provides a rational, expert-based approach to diagnosing and managing TCHD., Methods: The guidelines were developed by the Hirschsprung Disease Interest Group members established by the American Pediatric Surgical Association (APSA) Board of Governors. Group discussions, literature review, and expert consensus were used to summarize the current knowledge regarding diagnosis, staged approach, the timing of pull-through, and pre-and postoperative management in children with TCHD., Results: This paper presents recommendations for managing TCHD before and after reconstruction, including diagnostic criteria, surgical approaches, bowel management, diet, antibiotic prophylaxis, colonic irrigations, and post-surgical considerations., Conclusions: A clear understanding of the unique challenges posed by TCHD and consensus on its treatment are lacking in the literature. This review standardizes this patient group's pre- and postoperative management., Level of Evidence: V., Competing Interests: Conflict of interest The authors report no conflict of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objectives: The understanding of the impact of tethered cord syndrome (TCS) on the physiology of the colorectal area is limited. Our aim was to describe anorectal and colonic motility in children with TCS and compare the findings to those of children with functional constipation (FC)., Methods: We conducted a retrospective review of children with TCS who had an anorectal manometry (ARM) performed at our institution from January 2011 to September 2023. We recorded demographics, medical and surgical history, clinical symptoms, and treatment at time of ARM, ARM findings (resting pressure, push maneuver, rectal sensation, rectoanal inhibitory reflex [RAIR], and RAIR duration), and the final interpretation of colonic manometry (CM) if performed. We identified age and sex-matched control groups of children with FC., Results: We included 24 children with TCS (50% female) who had ARM testing (median age at ARM 6.0 years, interquartile range 4.0-11.8 years). All children had constipation at time of ARM. Nineteen children had detethering surgery before ARM was performed. No significant differences in ARM parameters were found between children who had detethering surgery before ARM and children with FC. Among the 24 children, 14 also had a CM performed (13/14 after detethering surgery). No significant differences in colonic motility were found between children with a history of TCS and children with FC., Conclusions: Anorectal physiology and colonic motility are similar between children with a history of TCS and children with FC, suggesting that the underlying pathophysiology of defecatory disorders in children with and without history of TCS is similar., (© 2024 The Author(s). Journal of Pediatric Gastroenterology and Nutrition published by Wiley Periodicals LLC on behalf of European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.)

Rendezvous with sperm whales for biological observations is made challenging by their prolonged dive patterns. Here, we propose an algorithmic framework that codevelops multiagent reinforcement learning-based routing (autonomy module) and synthetic aperture radar-based very high frequency (VHF) signal-based bearing estimation (sensing module) for maximizing rendezvous opportunities of autonomous robots with sperm whales. The sensing module is compatible with low-energy VHF tags commonly used for tracking wildlife. The autonomy module leverages in situ noisy bearing measurements of whale vocalizations, VHF tags, and whale dive behaviors to enable time-critical rendezvous of a robot team with multiple whales in simulation. We conducted experiments at sea in the native habitat of sperm whales using an "engineered whale"-a speedboat equipped with a VHF-emitting tag, emulating five distinct whale tracks, with different whale motions. The sensing module shows a median bearing error of 10.55° to the tag. Using bearing measurements to the engineered whale from an acoustic sensor and our sensing module, our autonomy module gives an aggregate rendezvous success rate of 81.31% for a 500-meter rendezvous distance using three robots in postprocessing. A second class of fielded experiments that used acoustic-only bearing measurements to three untagged sperm whales showed an aggregate rendezvous success rate of 68.68% for a 1000-meter rendezvous distance using two robots in postprocessing. We further validated these algorithms with several ablation studies using a sperm whale visual encounter dataset collected by marine biologists.

The conventional approach to managing a newborn with cloacal exstrophy typically includes separating the cecal plate from between the two hemibladders, tubularizing it to be included in the fecal stream, creating an end colostomy, and bringing the two bladder halves together. This study introduces an alternative approach wherein the cecal plate is retained in its original position and designated for future use as an autoaugment of the bladder. Four cases of cloacal exstrophy cases managed between November 2019 and February 2024 are described, with surgical approach and postoperative outcomes reported. Two patients who underwent traditional reconstruction experienced bacterial overgrowth attributed to stasis in the cecal plate, which manifested in increased ostomy output and feeding intolerance. Treatment in these two cases was to remove the cecum from the fecal stream and use it instead for a bladder augment. Learning from these cases, the third and fourth newborn's approach involved retaining the cecum in situ for autoaugmentation of the bladder and performing an ileal to hindgut anastomosis. No postoperative acidosis occurred in these patients. The alternative approach to the newborn management of cloacal exstrophy whereby the cecal plate is left in situ can decrease stasis and postoperative bacterial overgrowth. It allows for an autoaugmentation of the bladder and is technically easier than the traditional rescue of the cecal plate from within the two hemibladders., Competing Interests: Conflict of Interest None declared., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. ( https://creativecommons.org/licenses/by/4.0/ ).)

Study Objective: Mullerian duct anomalies are common in females with anorectal malformations (ARMs), although there are no universally recommended screening protocols for identification. Historically, at our institution, we have recommended a screening pelvic ultrasound (PUS) 6 months after thelarche and menarche. We aimed to evaluate outcomes associated with our post-thelarche screening PUS in females with ARMs., Methods: An institutional review board-approved retrospective chart review was performed for all female patients 8 years old or older with ARMs and documented thelarche. Data were collected on demographic characteristics and clinical course. The primary outcome was adherence to the recommended PUS. Secondary outcomes included imaging correlation with suspected Mullerian anatomy and need for intervention on the basis of imaging findings., Results: A total of 112 patients met the inclusion criteria. Of them, 87 (77.7%) completed a recommended post-thelarche screening PUS. There were no differences in completion on the basis of age, race, establishment with a primary care provider, insurance status, or type of ARM. Nine patients (10.3%) had findings on their PUS that did not correlate with their suspected Mullerian anatomy; five (5.7%) required intervention, with two requiring menstrual suppression, two requiring surgical intervention, and one requiring further imaging., Conclusion: Most patients completed the recommended post-thelarche screening PUS. In a small subset of patients, PUS did not correlate with suspected Mullerian anatomy and generated a need for intervention. Post-thelarche PUS can be a useful adjunct in patients with ARMs to identify gynecologic abnormalities., Competing Interests: Conflicts of Interest The authors have no conflicts of interest to disclose., (Copyright © 2024. Published by Elsevier Inc.)

Background: Children with colorectal diseases such as anorectal malformations (ARM), Hirschsprung disease (HD), and functional constipation (FC) undergo bowel management programs (BMPs) to achieve cleanliness. While patient outcomes, such as cleanliness and quality of life, are well understood, patient experience, such as relationships, ability to participate in sports, and independence and self-confidence is less well understood. We aimed to assess the relationship between BMP and patient experience., Methods: A cross-sectional survey was administered to 295 patients ≥3 years old with ARM, HD, and FC completing BMP. The survey contains 22 questions regarding patient-reported experience measures (PREMs) and 11 regarding patient-reported outcomes measures (PROMs). Each was graded on a Likert scale, with higher scores meaning better experience. Scores were compared by demographics and clinical characteristics and logistic regression was performed controlling for clinically significant variables. A p-value of ≤0.05 was significant., Results: There were 205 eligible respondents (69.5%) with a median age of 8.9 years [IQR: 6.1-12.4]. ARM was most common (51.2%) and most achieved cleanliness on BMP (69.3%). There were no differences in experience scores by age, diagnosis, or bowel regimen. Patients that were clean had significantly higher PREM scores (67.7 [IQR: 64.0-83.0] vs. 64.8 [IQR: 55.0-70.1], p = 0.0002) and PROM scores (36.8 [IQR: 33.0-41.0] vs. 34.0 [31.0-38.5], p = 0.005). On regression analysis, cleanliness remained a strongly significant predictor of positive experience scores (β 7.37, SE 1.86, p < 0.0001)., Conclusions: Achieving cleanliness was associated with positive patient experience of bowel management programs. This finding suggests that achieving cleanliness, regardless of regimen, may allow patients the best functional and experiential outcomes., Competing Interests: Conflicts of interest The authors have no conflicts of interest to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Children with Hirschsprung disease (HSCR) proximal to the splenic flexure or those needing a redo pull-through (PT) are at risk for tension and ischemia of the PT which could result in leak, stricture, or loss of ganglionated bowel. Colonic derotation is a technique used to minimize tension and avoid duodenal obstruction. The aim of this study was to describe this technique and outcomes in a series of patients requiring this intervention., Methods: All patients underwent initial diversion and colonic mapping. The derotation procedure involves mobilization of the remaining colon, counterclockwise rotation via the stoma closure site, placement of the pull through (the right colon) lying on the right of the pelvis, and ligation of the middle colic artery with preservation of the marginal branch running from the ileocolic artery. This maneuver prevents compression of the duodenum by the mesenteric vessels and allows for an isoperistaltic, tension-free anastomosis. Intraoperative indocyanine green fluorescence angiography (ICG-FA) was utilized in many of the cases to map the blood supply of the pull-through colon. We reviewed outcomes for all children with HSCR who underwent colonic derotation from 2014 to 2023. Descriptive statistics were performed., Results: There were 37 children included. Most were male (67.5%) with the original transition zone proximal to the rectosigmoid (81.1%). The median age at PT was 9.3 months [6.1-39.7]. Median operative time was 6.6 h [4.9-7.4] and 19 cases (51.4%) used ICG-FA. Most children had no 30-day postoperative complications (67.6%); in those who did develop complications, readmissions for electrolyte imbalance was most common (50.0%). There were zero cases of anastomotic leak at PT anastomosis. At long-term follow up, median 4.4 years [2.3-7.0], three children (8.1%) developed an anastomotic stricture, all were amenable to anal dilation, and five experienced episodes of enterocolitis (14.7%). Most children had between 1 and 4 stools per day (58.8%)., Conclusion: Colonic derotation is a useful strategy to ensure well-perfused colonic length, protect the marginal artery blood supply, avoid duodenal compression, and ensure a tension-free anastomosis with minimal complications., Type of Study: Original research, retrospective cohort., Level of Evidence: III., Competing Interests: Conflicts of interest The authors have no conflicts of interest to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Girls with cloacal malformation are at risk of bladder dysfunction, with nearly 90% exhibiting some degree of dysfunction. Surgical dissection, particularly with total urogenital mobilization (TUM), has been hypothesized as a cause of worsening bladder function despite this population commonly having associated vertebral and spinal cord abnormalities that may also explain bladder dysfunction. More recently there has been great effort to select the appropriate surgical technique for cloacal repair in each patient in order to minimize dissection and potential damage to the bladder. We aimed to evaluate the effect of surgical cloacal repair on bladder function based on pre and post-surgery urodynamics (UDS) testing., Methods: A prospectively collected database of patients with anorectal malformation at a single center was queried for girls with cloacal malformations who had undergone surgical repair from 2015 to 2022. It is our current protocol to perform UDS before and after cloacal repair. Only patients who completed both pre and post-surgery UDS were included. UDS were evaluated and classified using the UMPIRE protocol., Results: A total of 48 patients were included in the cohort. The majority of patients (79.2%) had stable or improved UDS post-op leaving 10 patients (20.8%) who had worsening UDS. Long common channel (≥3 cm) was the only factor significantly associated with worsening UDS. (p = 0.03) Nearly 30% (n = 8) of those undergoing UGS had worse post-op UDS compared to 9.5% (n = 2) with TUM. All patients who worsened UDS initially had safe UDS that changed to intermediate, except for one who worsened to hostile in the setting of significant social challenges and non-compliance. Only common channel length was predictive of worsening UDS, while the type of surgical approach and spine status were not. While the overall risk of worsening UDS after TUM is only 9.5%, patients with normal spines undergoing TUM had the lowest risk, seen in only one in 15 patients (6.6%)., Conclusions: Common channel length was the most significant predictor of worsening UDS, while spine status and surgical technique (TUM vs UGS) did not significantly impact this finding. By following this established surgical protocol based on common channel and urethral lengths, is rare for the surgical cloacal repair to result in worsening post-op UDS, particularly in those undergoing TUM for short common channel and normal spine., Competing Interests: Conflicts of interest None., (Copyright © 2024 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Objective:  The purpose of the study was to determine if antegrade continence enema (ACE) alone is an effective treatment for patients with severe functional constipation and segmental colonic dysmotility., Methods:  A retrospective study of patients with functional constipation and segmental colonic dysmotility who underwent ACE as their initial means of management. Data was collected from six participating sites in the Pediatric Colorectal and Pelvic Learning Consortium. Patients who had a colonic resection at the same time as an ACE or previously were excluded from analysis. Only patients who were 21 years old or younger and had at least 1-year follow-up after ACE were included. All patients had segmental colonic dysmotility documented by colonic manometry. Patient characteristics including preoperative colonic and anorectal manometry were summarized, and associations with colonic resection following ACE were evaluated using Fisher's exact test and Wilcoxon rank-sum test. p -Values of less than 0.05 were considered significant. Statistical analyses and summaries were performed using SAS version 9.4 (SAS Institute Inc., Cary, North Carolina, United States)., Results:  A total of 104 patients from 6 institutions were included in the study with an even gender distribution (males n  = 50, 48.1%) and a median age of 9.6 years (interquartile range 7.4, 12.8). At 1-year follow-up, 96 patients (92%) were successfully managed with ACE alone and 8 patients (7%) underwent subsequent colonic resection for persistent symptoms. Behavioral disorder, type of bowel management, and the need for botulinum toxin administered to the anal sphincters was not associated with the need for subsequent colonic resection. On anorectal manometry, lack of pelvic floor dyssynergia was significantly associated with the need for subsequent colonic resection; 3/8, 37.5% without pelvic dyssynergia versus 1/8, 12.5% ( p  = 0.023) with pelvic dyssynergia underwent subsequent colonic resection., Conclusion:  In patients with severe functional constipation and documented segmental colonic dysmotility, ACE alone is an effective treatment modality at 1-year follow-up. Patients without pelvic floor dyssynergia on anorectal manometry are more likely to receive colonic resection after ACE. The vast majority of such patients can avoid a colonic resection., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: Our objective was to evaluate long-term outcomes of sacral nerve stimulation (SNS) for children with functional and organic defecation disorders., Methods: We performed a prospective study of children <21 years of age who started SNS treatment between 2012 and 2018. We recorded demographics, medical history, and diagnostic testing. We obtained measures of symptom severity and quality of life at baseline and follow up at 1, 6, 12, 24, 36, 48, and ≥60 months. Successful response was defined as bowel movements >2 times/week and fecal incontinence (FI) <1 time/week. Families were contacted to administer the Glasgow Children's Benefit Inventory and to evaluate patient satisfaction., Key Results: We included 65 patients (59% female, median age at SNS 14 years, range 9-21) with median follow-up of 32 months. Thirty patients had functional constipation (FC), 15 had non-retentive FI (NRFI), and 16 had an anorectal malformation (ARM). The percentage with FI <1 time/week improved from 30% at baseline to 64% at 1 year (p < 0.001) and 77% at most recent follow-up (p < 0.001). Patients with FC, NRFI, and ARM had sustained improvement in FI (p = 0.02, p < 0.001, p = 0.02). Patients also reported fewer hard stools (p = 0.001). Bowel movement frequency did not improve after SNS. At most recent follow-up, 77% of patients with a functional disorder and 50% with an organic disorder had responded (p = 0.03). Nearly all families reported benefit., Conclusions and Inferences: SNS led to sustained improvement in FI regardless of underlying etiology, but children with functional disorders were more likely to respond than those with organic disorders., (© 2024 John Wiley & Sons Ltd.)

Background: For children with constipation and fecal incontinence treated with antegrade continence enemas (ACE), a fluoroscopic study with contrast administered via appendicostomy/cecostomy can define the anatomy of the colon and simulate the flush to investigate associated symptoms or inadequate response. These studies can at times show retrograde flow into the small intestine. Our objective was to investigate the significance of this finding., Methods: We reviewed studies at our institution with contrast administered via appendicostomy/cecostomy in children treated with ACE, identifying those demonstrating retrograde flow of contrast. We recorded demographics, medical history, interventions, and outcomes., Results: We identified 162 studies (52% male, median age 10.7 years) with contrast via appendicostomy (76%) or cecostomy (24%). Diagnoses included anorectal malformation (38%), spinal cord anomaly (26%), functional constipation (24%), colonic dysmotility (18%), and Hirschsprung disease (12%). Fifty-nine (36%) studies showed retrograde flow: 28/59 children (48%) were not responding adequately and 21/59 (36%) had symptoms with ACE. Children with retrograde flow were more likely to have symptoms with ACE than those without (36% vs. 15%, p < 0.01). Fourteen children underwent interventions for this finding, including administering flushes more distally (4/8 responded), changing positioning of the child during flush administration, (1/2 responded), and slowing administration (1/1 responded). Retrograde flow was associated with younger age (p < 0.01), not sex or underlying diagnosis., Conclusion: Identifying retrograde flow during studies with contrast administered via appendicostomy/cecostomy can be useful for children with a poor response or symptoms associated with ACE, as adjustments to the mechanics of the flush can alleviate those symptoms., Level of Evidence: Prognostic study, Level III., (© 2024 European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.)

Seven of the top ten leading causes of death in the United States are due to chronic diseases and treating these accounts for 86 percent of our nation's health care costs. The workplace offers an environment to implement chronic disease prevention strategies, such as worksite wellness programs, due to the large amount of time spent at the worksite daily by employees. As a result of COVID-19, many organizations began to change their workdays (i.e., working from home). This research sought to understand what, if any, implications the COVID-19 epidemic had on worksite wellness programming. Semistructured interviews were employed and recorded via Zoom conferencing to gather qualitative data. Four themes were identified: (a) relationship building among remote employees, (b) creativity in how to carry out program components, (c) increased physical activity and work-life balance, and (d) increased knowledge of health issues and mental health resources. Both challenges and successes were reported within themes. The main finding from this research indicates a mostly positive experience for worksite wellness programs during the COVID-19 epidemic. Many organizations have continued nontraditional work environments and the lessons learned from this study can both encourage and provide ideas for how to create and continue a worksite wellness program outside of the normal face-to-face working environment.

Competing Interests: None declared.

Background: In children with cloacal malformations, renal dysfunction is a constant concern, with reported incidence as high as 50%. Multiple factors exist that may impair renal function. Our institution follows a strict renal protection protocol in this population. Incidence of renal dysfunction in these patients is unknown., Objective: We aimed to evaluate incidence of renal dysfunction while implementing this protocol in a cohort of children with cloacal malformation., Study Design: We reviewed a prospectively collected database of children with cloacal malformations managed at a single institution since implementation of a renal protection protocol. This involves regular laboratory evaluation, appropriate selection of total urogenital mobilization or urogenital separation, proactive imaging in patients with signs of impending renal dysfunction or urinary retention, and early catheterization teaching and implementation if necessary. Glomerular filtration rate (GFR) was calculated with the Schwartz formula and CKD grades assigned per standard definitions. Renal dysfunction was defined as CKD grade 3b or higher, need for renal replacement therapy (RRT) or transplantation. Descriptive statistics were computed., Results: A total of 105 children were managed under this protocol with a median follow-up of 4.2 years [IQR: 2.0-5.9]. Six children (5.7%) had renal dysfunction at most recent follow-up; of these children, only three (2.9%) progressed from normal renal function at initial evaluation to renal dysfunction (Table). No child with normal presenting renal function thus far has progressed to require dialysis or transplantation., Discussion: Previous literature estimated rates of renal dysfunction in cloaca patients as high as 50%; in contrast, we demonstrate a rate of progression to renal dysfunction of 2.9% in girls following a strict renal protection protocol. Most children who developed renal dysfunction had dysfunctional kidneys on presentation. This suggests that preservation of renal function may be possible in early childhood with a strict, multi-disciplinary renal protection protocol., Conclusion: In our cohort of patients with cloacal malformations following a strict renal protection protocol, incidence of progressive renal dysfunction is low at 2.9%. Most who go on to renal dysfunction present with impaired renal function., Competing Interests: Conflict of interest The authors have no conflicts of interest to disclose., (Copyright © 2024 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Background: Multiple factors impact ability to achieve urinary continence in cloacal malformation including common channel (CC) and urethral length and presence of spinal cord abnormalities. Few publications describe continence rates and bladder management in this population. We evaluated our cohort of patients with cloacal malformation to describe the bladder management and continence outcomes., Methods: We reviewed a prospectively collected database of patients with cloacal malformation managed at our institution. We included girls ≥3 years (y) of age and evaluated their bladder management methods and continence. Dryness was defined as <1 daytime accident per week. Incontinent diversions with both vesicostomy and enterovesicostomy were considered wet., Results: A total of 152 patients were included. Overall, 93 (61.2%) are dry. Nearly half (47%) voided via urethra, 65% of whom were dry. Twenty patients (13.1%) had incontinent diversions. Over 40% of the cohort performed clean intermittent catheterization (CIC), approximately half via urethra and half via abdominal channel. Over 80% of those performing CIC were dry. In total, 12.5% (n = 19) required bladder augmentation (BA). CC length was not associated with dryness (p = 0.076), need for CIC (p = 0.253), or need for abdominal channel (p = 0.497). The presence of a spinal cord abnormality was associated with need for CIC (p = 0.0117) and normal spine associated with ability to void and be dry (p = 0.004) CONCLUSIONS: In girls ≥ 3 y of age with cloacal malformation, 61.2% are dry, 65% by voiding via urethra and 82% with CIC. 12.5% require BA. Further investigation is needed to determine anatomic findings associated with urinary outcomes., Level of Evidence: IV., Competing Interests: Conflict of interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: Congenital anorectal stenosis is managed by dilations or operative repair. Recent studies now propose use of dilations as the primary treatment modality to potentially defer or eliminate the need for surgical repair. We aim to characterize the management and outcomes of these patients via a multi-institutional review using the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC) registry., Methods: A retrospective database review was performed using the PCPLC registry. The patients were evaluated for demographics, co-morbidities, diagnostic work-up, surgical intervention, current bowel management, and complications., Results: 64 patients with anal or rectal stenosis were identified (57 anal, 7 rectal) from a total of 14 hospital centers. 59.6% (anal) and 42.9% (rectal) were male. The median age was 3.2 (anal) and 1.9 years (rectal). 11 patients with anal stenosis also had Currarino Syndrome with 10 of the 11 patients diagnosed with a presacral mass compared to only one rectal stenosis with Currarino Syndrome and a presacral mass. 13 patients (22.8%, anal) and one (14.3%, rectal) underwent surgical correction. Nine patients (8 anal, 1 rectal) underwent PSARP. Other procedures performed were cutback anoplasty and anterior anorectoplasty. The median age at repair was 8.4 months (anal) and 10 days old (rectal). One patient had a wound complication in the anal stenosis group. Bowel management at last visit showed little differences between groups or treatment approach., Conclusion: The PCPLC registry demonstrated that these patients can often be managed successfully with dilations alone. PSARP is the most common surgical repair chosen for those who undergo surgical repair., Level of Evidence: III., Competing Interests: Conflict of interest Many authors are members of this consortium but have no financial or further competing interests in the outcomes of the study. All other authors have nothing to declare., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)