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Experience report December 2018
... how is the treatment of children with anal atresia in a developing country?
by Dr. Wilfried Krois
With the sixth mission of the association “Helping Hands for Anorectal Malformations International” we were able to help numerous children in Honduras for the second time in 2018 (see experience report January 2018 ) to receive adequate care for their congenital malformations of the anus or colon.
As in previous missions, we met many familiar faces again this time, many patients from last time received a further step in their often gradual steps with several necessary interventions. But many of our well-known “Helping Hands” were also on site for this mission and, with their organization and continuous patient care, made this mission possible this time really smoothly and efficiently.
The employee, financed by donations, worked together with the organizer and head of Fundacion MAR, Dr. Juan Craniotis, caring about the aftercare of our patients. Especially in the field of colorectal surgery for children, care around and especially after the operations is of the greatest importance. One of the best-known and leading pediatric surgeons in the field and also supporter of our operations through his association “Colorectal Team Overseas” Prof. Marc Levitt teaches in his lectures the principle “The treatment of a child with congenital malformations of the anus requires about 100 hours of medical care - 4 Hours of operation and 96 hours of follow-up care. ”. This impressively illustrates the importance of follow-up treatment, which also appears to be particularly important to us and that is why we use the donations we have collected for these purposes throughout the year.
This time, too, we were able to provide very good results from our last corrections to the last operative step of ostomy closure. In Honduras, treating a simple malformation of the anus is a three-step process. The first step is carried out by the pediatric and general surgeons on site directly after the birth in the creation of an artificial anus. This is absolutely essential for children with anal atresia as the first step in the developing world to survive. Without this artificial anus, these children would die within a few days due to intestinal perforations. In principle, a primary correction of anal atresia is only possible in some cases with mild forms, but in Honduras it is almost impossible due to the lack of medical care. In a second surgical step, the correction of the anus is carried out, here moving depending on the complexity of the malformation the operation times between 2 and 5 hours, in some cases significantly longer. Since the child continues to retain the artificial anus, the newly operated anal area has time to heal without the anus being needed to defecate - this avoids infections and long hospital stays.
During this mission we were able to let some of the children home one day after the operation. In a further third step, a few months after the correction - or in the case of our patients in Honduras during our next assignment - the artificial anus can be closed. From that point on it also shows how the intestines will function. In children who are out of the diaper age, it will soon be possible to estimate how continence, i.e. the ability to hold a chair willingly without losing it in their pants or diaper, will be. Many children achieve a very good function of their sphincter muscle, can control it at will, are clean and can go about a normal life, attend school without being stigmatized. We have already shown in a scientific paper  what effects an artificial anus has on affected families. Unlike in richer and developed countries, the artificial intestinal exits are only supplied with towels and diapers instead of odor- and liquid-tight bags. In addition to irritated skin around the artificial anus, the consequences are hygienic impairment, smells and, as a result, social exclusion and isolation. The older the children are, the more difficult the situation is, the children are teased at school and, due to the resulting pressure, leave school very early. The vicious circle of poverty and a lack of education can hardly be broken here.
Unfortunately, regardless of the type and quality of surgical correction, some children do not achieve sufficient continence. Here, the severity of the congenital malformation limits the function - unfortunately, the lack of muscle fibers and nerve connections cannot yet be replaced even with the most modern medical techniques. Follow-up care is particularly important for these children - even if no real stool or urinary continence can be achieved, at least one social continence can protect against social exclusion and enable a reasonably normal life without daily loss of stool. With daily colonic irrigation, the colon can be emptied to such an extent that no stool is lost for a period of 1-2 days and the patients do not have to worry about bad smells, dirty pants or even wearing diapers into adulthood.
Every year we also experience cultural differences, some of which we were not aware of before - for example, it seems to be an impossible idea for many families in Latin America to give their child rectal irrigation or to empty the bladder through the urethra using a catheter. Thoughts about the possible effects of such interventions and feelings of shame still outweigh the hoped-for benefits of social continence. A large part of our work also relates to training and education on these very sensitive topics.
In total, we were able to operate on 46 children again this time, and many of them were completed with surgical interventions and included in the follow-up care. We are also proud to bring the right and necessary materials with us and to establish new, modern techniques based on our experience with the possibilities on site. With the support of our donors and sponsors, this time we were able to carry out the first treatment of Hirschsprung's disease with an assisting laparoscopy and thus avoid a large abdominal incision. With the support of our pediatric urologist, we were also able to help some boys with congenital malformations of the penis.
Since our five days of surgery in the Ruth Paz Clinic were interrupted this time by a Sunday on which we were not allowed to operate, we had the opportunity to get to know the beautiful sides of the country for the first time and a wonderful excursion into the rainforest on the northwest coast enjoy a refreshing swim in a waterfall pool. The beautiful and touristic part of Honduras had never come to our consciousness. In this sense - it was a pleasure and we will definitely come back!
Honduras is located in Latin America and is similar both in area and with its almost 9 million inhabitants to the size of Austria. In addition to the capital Tegucigalpa, San Pedro Sula is one of the second largest cities in the country. The rate of congenital malformations of the anus is similar to that in Austria, affecting around one in 4000 newborns per year. With a birth rate of slightly more than 200,000 children per year, this results in an expected number of around 30-40 newly affected patients per year. Medical care is extremely poor, there are around 0.37 doctors for every 100,000 inhabitants (comparison with Austria: more than 470 doctors per 100,000 inhabitants). For the whole country, 12 pediatric surgeons take care of all surgical interventions on children (comparison with Austria: around 80 pediatric surgeons). The country is characterized by an extremely high crime rate and corruption. Most of the people live below the poverty line, have no health insurance and receive inadequate medical care.
 Krois W, Dingemans AJM, Hernández PX, Metzelder ML, Craniotis Rios J, Reck-Burneo CA. Sociodemographics and the impact of a colostomy to indigent families and children with colorectal disorders in Honduras. J Pediatr Surg 2018; 53: 841–6.
6th Brigade for Anorectal Malformations in Honduras, December 6-13, 2018
Host and medical director: Juan Craniotis Rios (HON)
Team: Pastora Xiomara Hernandez (HON), Carlos A. Reck (AUT), Wilfried Krois (AUT), Alejandra Vilanova (ESP), Drew Rideout (USA), Alexander Springer (AUT), Renate Fartacek (AUT), Edin Rápalo Romero (HON), Maria Camila Egas (HON), Fernando Acosta (HON), Laura Castro (HON)
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