ABSTRACT
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Purpose
This study aimed to evaluate postoperative outpatient follow-up practices among pediatric surgeons in Korea for five common congenital diseases: esophageal atresia with tracheoesophageal fistula (EA/TEF), anorectal malformation (ARM), Hirschsprung’s disease (HSCR), choledochal cyst (CC), and inguinal hernia (IH).
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Methods
A web-based survey consisting of 43 questions was distributed to members of the Korean Association of Pediatric Surgeons. The survey assessed the timing, frequency, and duration of outpatient follow-up, as well as disease-specific practices.
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Results
Of 154 invited surgeons, 45 (29.2%) responded. Most scheduled the first follow-up visit within one week after discharge. During the first postoperative year, follow-up visits were commonly held every three months, followed by six months or annual intervals. Most surgeons concluded follow-up before age 18; however, 15.6%–37.8% reported continuing follow-up into adulthood depending on the disease. Variation was observed in disease-specific practices: 44.4% routinely performed contrast studies for EA/TEF follow-up; sizes #14–15 Hegar dilators were most used in ARM; only 6.7% performed routine rectal irrigation in HSCR. For CC, 88.9% checked both blood tests and ultrasonography. Most IH patients received only one follow-up visit.
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Conclusion
While early postoperative follow-up practices among pediatric surgeons in Korea appear relatively consistent, wide variation exists in long-term strategies and disease-specific protocols. This reflects the tendency to rely on individual clinical judgment and highlights the need for standardized, national consensus.
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Keywords: Follow-up studies; Surveys and questionnaires; Congenital abnormalities
INTRODUCTION
Advances in pediatric surgery have significantly improved the survival and quality of life of children with congenital and acquired surgical conditions. However, surgery alone is not sufficient to ensure optimal long-term outcomes. Postoperative follow-up plays a critical role in identifying delayed complications, monitoring functional recovery, and supporting the developmental needs of patients through childhood.
The need for long-term follow-up in pediatric surgical patients varies depending on the characteristics of disease and the risks of delayed complications. For instance, patients with esophageal atresia and tracheoesophageal fistula (EA/TEF) frequently experience esophageal dysmotility, gastroesophageal reflux, and recurrent respiratory infections, all of which may require prolonged monitoring [
1]. In anorectal malformation (ARM), long-term bowel dysfunction, fecal incontinence, and associated urologic anomalies necessitate continued evaluation and individualized management [
2]. Similarly, children with Hirschsprung’s disease (HSCR) remain at risk of chronic constipation and severe colitis even after definitive surgery, requiring sustained follow-up [
3]. In patients with choledochal cysts (CCs), the potential for biliary stricture and cholangiocarcinoma justifies ongoing imaging and liver function assessment [
4]. In contrast, inguinal hernia (IH) is generally associated with a low risk of long-term complications, and follow-up is typically limited to the early postoperative period [
5]. These disease-specific considerations highlight the importance of examining current follow-up practices and the variation among pediatric surgeons.
Despite the recognized importance of postoperative follow-up, no standardized national guidelines currently exist in Korea regarding the duration, frequency, or content of such care in pediatric surgical patients. In clinical practice, follow-up strategies are often left to the discretion of individual surgeons or institutions, which may result in significant variability and inconsistency in patient care.
To address this gap, we conducted a nationwide survey of pediatric surgeons in Korea. The aim of this study was to describe current follow-up practices for five common congenital surgical disease and to explore the degree of variation among clinicians. By identifying patterns and discrepancies, we hope to provide evidence that may support the development of standardized follow-up protocols and long-term care pathways in pediatric surgical care.
METHODS
1. Study design and objectives
This study employed a cross-sectional survey design to investigate outpatient follow-up practices among pediatric surgeons in Korea. The objective was to examine patterns and variations in the postoperative management of five common pediatric surgical conditions: EA/TEF, ARM, HSCR, CC, and IH.
2. Participants and recruitment
The survey was conducted in April 2021 using a web-based questionnaire created with Google Forms. It was distributed to all full (n=65) and associate (n=89) members of the Korean Association of Pediatric Surgeons. Eligible participants were invited to complete the survey via email and mobile text message. Completion of the anonymous questionnaire was considered to imply informed consent.
3. Survey instrument
The questionnaire consisted of 43 items and was developed by the study team based on a review of existing literature and clinical practice considerations. It was structured to gather data including the timing of the first postoperative follow-up visit, frequency and duration of ongoing follow-up, and disease-specific practices such as use of imaging, laboratory tests, and physical examinations.
In particular, the survey sought to examine variation in clinical routines for each disease. For example, surgeons were asked whether they routinely performed contrast studies after EA/TEF repair, which size of Hegar dilator they typically used for ARM follow-up, and whether blood tests or imaging were employed in monitoring CC. Multiple-response options were included where relevant, such as for the use of imaging or laboratory tests. For certain items, multiple responses were permitted to reflect real-world clinical decision-making.
4. Data collection and analysis
All responses were collected anonymously through the online platform. All completed questionnaires were received by May 2021. Descriptive statistics were used to summarize survey results. Frequencies and percentages were calculated for categorical variables. Microsoft Excel (Microsoft Corp., Redmond, WA, USA) was used for data analysis, with results summarized as frequencies and percentages.
RESULTS
1. Outpatient follow-up visit schedule
A total of 45 pediatric surgeons (response rate 29.2%) participated. Most pediatric surgeons scheduled the initial outpatient follow-up visit approximately one week after discharge for patients with EA/TEF, ARM, and HSCR. Specifically, 34 (75.6%) of EA/TEF, 37 (82.2%) of ARM, and 34 (75.6%) of HSCR patients attended their first follow-up visit at this interval (
Table 1). During the first postoperative year, follow-up visits were typically arranged every three months, with most surgeons transitioning to six-month intervals thereafter. A similar approach was observed for CC, with 33 patients (73.3%) receiving their first follow-up one-week post-discharge. However, follow-up for CC patients frequently shifted to an annual schedule after the first postoperative year.
For most diseases, outpatient follow-up generally concluded before the patient reached 18 years of age. Specifically, follow-up was discontinued during adolescence for 38 (84.4%) EA/TEF, 35 (77.8%) ARM, and 36 (80.0%) HSCR cases, with many surgeons ending follow-up around elementary school age (
Table 2). In contrast, follow-up for CC was extended into adulthood by 17 surgeons (37.8%), suggesting a prolonged follow-up period for this condition compared to the others.
For EA/TEF, routine esophagography was not widely practiced with 25 (55.6%) of surgeons opting not to perform this study during follow-up (
Table 3). Among the 20 surgeons (44.4%) who conducted regular contrast studies, the most common interval was one month postoperatively. In ARM cases, there was variation in the largest Hegar dilator size used during follow-up; sizes #14 and #15 were most commonly used, reported by 14 (31.1%) and 16 (35.6%) surgeons, respectively. For HSCR, only three respondents (6.7%) reported performing routine rectal irrigation during follow-up visits. In CC patients, blood tests and ultrasonography were the predominant follow-up study modalities, each reported by 40 (88.9%) surgeons. This question permitted multiple responses, allowing surgeons to select more than one imaging or test modality.
For IH, the initial outpatient follow-up visit was most commonly scheduled for one week post-discharge, reported by 40 (88.9%) respondents (
Table 4). Subsequent follow-up visits were generally not preferred, as presented by 35 (77.8%) surgeons. Of the 10 surgeons who conducted a second follow-up, 7 scheduled it three months after the initial visit. Routine additional imaging studies during outpatient follow-up were rarely performed, with 41 respondents (91.1%) indicating they did not routinely include imaging.
DISCUSSION
In this survey of pediatric surgeons in Korea, a generally consistent trend was observed in the timing of the initial postoperative outpatient visit, with most respondents scheduling it within one week following discharge. During the first postoperative year, follow-up visits were most commonly conducted at three-month intervals, transitioning to six-month or longer intervals thereafter.
In contrast, wide variability was noted in the duration and disease-specific practice for long-term follow-up, particularly with regard to continuation of care into adulthood. While most respondents indicated that outpatient follow-up would be ended before the patient reached 18 years of age, the specific timing varied considerably depending on factors such as postoperative duration, nutritional milestones, and school entry. Notably, a higher-than-expected proportion of respondents reported continuing follow-up beyond the pediatric age range. Depending on the disease, 15.6% to 37.8% of pediatric surgeons indicated that they would continue long-term follow-up observations into adulthood. Although these differences were not substantial, they highlight the lack of standardized national consensus and suggest that postoperative follow-up practices remain highly dependent on individual clinical judgment and institutional policies.
The need for long-term follow-up in pediatric surgery is well-established, particularly for congenital disease that may result in delayed complications affecting respiratory, gastrointestinal, growth impairment, and social and psychological development. For instance, while follow-up beyond adolescence is often warranted for EA/TEF patients due to risks of gastroesophageal reflux disease, recurrent respiratory infections, and esophageal motility dysfunction, most respondents in this study reported discontinuing follow-up by elementary school age [
1,
6,
7]. Similarly, in ARM and HSCR, functional outcomes such as constipation, fecal incontinence, and enterocolitis require prolonged evaluation, however follow-up often ended during elementary school years, similar to the findings in EA/TEF in this study [
2,
3,
8,
9]. In contrast, follow-up for CC was more prolonged, with more than one-third of surgeons in this study continuing follow-up into adulthood, likely reflecting clinical concerns regarding biliary stricture, stone formation, or even malignancy [
4]. Meanwhile, IH is generally known to have a low risk of long-term complications, so most respondents completed follow-up observation only once after surgery (88.9%) and did not perform additional imaging study (91.1%) [
5]. As such, some differences in current follow-up practices and disease-specific considerations are observed.
The survey response rate for our survey was 29.2%; 46.2% for regular members and 16.8% for associate members. Although the results may not fully reflect follow-up practices within the target population, respondents in this survey are considered to be fairly representative of pediatric surgery hospitals across Korea with given the number of respondents and the number of current pediatric surgery hospitals in Korea. Furthermore, since the purpose of our survey was to assess the degree of variation in practice in the absence of national guidelines, we do not believe that the potential sampling bias would have significantly affected our results.
As a self-reported survey, the findings may be subject to recall bias or response bias. The survey did not include objective clinical data or patient outcomes, and the actual implementation of follow-up strategies may differ from reported practices in the survey. The design of the questionnaire questions may have limited the validity of the survey results. Not all questions in the questionnaire provided a blank option to comment freely [
10,
11]. This was anonymous questionnaire and did not request demographic information for respondents except whether they were regular or associate members. It may have been helpful to interpret and understand the study results if demographic information regarding respondents’ work environment and clinical experience, such as hospital location, whether it was a tertiary hospital, and annual number of surgeries for the five diseases surveyed, had been provided.
Nevertheless, this survey provides a comprehensively actual follow-up practices for key congenital diseases within Korea. While overall patterns of postoperative follow-up practices among pediatric surgeons in Korea were generally consistent, there were still meaningful variations in the duration and disease-specific strategies for long-term follow-up. This reflects the tendency to rely on individual clinical judgment and supports the need for future development of standardized, consensus-based guidelines for follow-up after surgery.
NOTES
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Conflict of Interest
No potential conflict of interest relevant to this article was reported.
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Author Contributions
Conceptualization: L.S.; Formal analysis: K.W.; Investigation: L.S.; Methodology: L.S.; Project administration: L.S., S.J.M.; Resources: S.J.M.; Software: P.S.; Supervision: S.J.M.; Visualization: P.S.; Writing - original draft: K.W.; Writing - review & editing: K.W., L.S.
Table 1.Outpatient follow-up visit schedule
Table 1.
|
Variables |
EA/TEF |
ARM |
HRSC |
CC |
|
Timing of the first outpatient follow-up visit after surgery |
|
1 wk after discharge |
34 (75.6) |
37 (82.2) |
34 (75.6) |
33 (73.3) |
|
2 wk after discharge |
9 (20.0) |
7 (15.6) |
11 (24.4) |
11 (24.4) |
|
1 mo after discharge |
2 (4.4) |
1 (2.2) |
- |
- |
|
3 mo after discharge |
- |
- |
- |
1 (2.2) |
|
Outpatient follow-up visit period during the first year after surgery |
|
Every month |
5 (11.1) |
14 (31.1) |
10 (22.2) |
6 (13.3) |
|
Every 2 mo |
8 (17.8) |
7 (15.6) |
7 (15.6) |
|
|
Every 3 mo |
25 (55.6) |
19 (42.2) |
27 (60.0) |
23 (51.1) |
|
Every 6 mo |
7 (15.6) |
2 (4.4) |
1 (2.2) |
16 (35.6) |
|
Others |
- |
3 (6.7) |
- |
- |
|
Outpatient follow-up visit period after the first year after surgery |
|
Every 3 mo |
4 (9.1) |
11 (24.4) |
8 (17.8) |
- |
|
Less than 6 mo |
- |
- |
- |
3 (6.7) |
|
Every 6 mo |
28 (63.6) |
24 (53.3) |
31 (68.9) |
16 (35.6) |
|
Annually |
7 (15.9) |
8 (17.8) |
5 (11.1) |
25 (55.6) |
|
None |
5 (11.4) |
- |
- |
1 (2.2) |
|
Others |
- |
2 (4.4) |
1 (2.2) |
- |
|
No answer |
1 (2.2) |
- |
- |
- |
Table 2.End of outpatient follow-up (end of outpatient follow-up visit before age 18)
Table 2.
|
Variables |
EA/TEF |
ARM |
HRSC |
CC |
|
Yes |
38 (84.4) |
35 (77.8) |
36 (80.0) |
28 (62.2) |
|
End point |
|
|
|
|
|
When eating baby food well |
1 (2.6) |
- |
- |
- |
|
When eating regular diet well |
7 (18.4) |
- |
- |
- |
|
Toilet training success |
- |
7 (2) |
7 (19.4) |
- |
|
Entering elementary school |
17 (45) |
20 (57.1) |
20 (55.6) |
3 (10.7) |
|
Senior grade in elementary school |
- |
1 (2.9) |
1 (2.8) |
- |
|
Entering middle school |
- |
- |
- |
2 (7.1) |
|
Entering high school |
- |
- |
- |
5 (17.9) |
|
High school graduation |
- |
2 (5.7) |
2 (5.6) |
- |
|
Age 18 |
- |
- |
- |
1 (3.6) |
|
1 yr after surgery |
3 (7.9) |
1 (2.9) |
- |
3 (10.7) |
|
2 yr after surgery |
1 (2.6) |
- |
2 (5.6) |
- |
|
3 yr after surgery |
3 (7.9) |
- |
- |
2 (7.1) |
|
5 yr after surgery |
6 (15.8) |
3 (8.6) |
4 (11.1) |
8 (28.6) |
|
10 yr after surgery |
- |
- |
- |
2 (7.1) |
|
No answer |
- |
1 (2.9) |
- |
2 (7.1) |
|
No (continued after age 18) |
7 (15.6) |
10 (22.2) |
9 (20.0) |
17 (37.8) |
|
Follow-up interval |
|
|
|
|
|
Every 6 mo |
- |
- |
- |
1 (5.9) |
|
Annually |
2 (28.6) |
4 (40) |
5 (55.6) |
10 (58.8) |
|
Every other year |
5 (71.4) |
5 (50) |
3 (33.3) |
6 (35.3) |
|
No answer |
- |
1 (10) |
1 (11.1) |
- |
Table 3.Disease-specific follow-up practices
Table 3.
|
Variables |
Value |
|
Routine esophagography during outpatient follow-up after EA/TEF surgery |
|
|
No |
25 (55.6) |
|
Yes |
20 (44.4) |
|
Timing of contrast study |
|
|
1 mo after surgery |
10 (50.0) |
|
3 mo after surgery |
6 (30.0) |
|
6 mo after surgery |
2 (10.0) |
|
1 yr after surgery |
1 (5.0) |
|
Annually |
1 (5.0) |
|
The largest Hegar dilator size used during outpatient follow-up after ARM surgery |
|
|
#13 |
1 (2.2) |
|
#14 |
14 (31.1) |
|
#15 |
16 (35.6) |
|
#16 |
7 (15.6) |
|
#17 |
3 (6.7) |
|
#18 |
1 (2.2) |
|
Finger |
3 (6.7) |
|
Routine rectal irrigation during outpatient follow-up after HRSC surgery |
|
|
No |
42 (93.3) |
|
Yes |
3 (6.7) |
|
Routine study during outpatient follow-up after CC excisiona)
|
|
|
Blood test |
40 (88.9) |
|
Ultrasonography |
40 (88.9) |
|
MRI |
6 (13.3) |
|
CT scan |
2 (4.4) |
Table 4.Follow-up practices for inguinal hernia
Table 4.
|
Variables |
Value |
|
Timing of the first outpatient follow-up visit after surgery |
|
|
2 days after discharge |
1 (2.2) |
|
1 wk after discharge |
40 (88.9) |
|
2 wk after discharge |
3 (6.7) |
|
No answer |
1 (2.2) |
|
Second outpatient follow-up visit |
|
|
No |
35 (77.8) |
|
Yes |
10 (22.2) |
|
Timing of the second outpatient follow-up visit following the initial outpatient visit |
|
|
1 wk |
1 (10.0) |
|
3 mo |
7 (70.0) |
|
1 yr |
2 (20.0) |
|
Additional imaging study during outpatient follow-up visit |
|
|
No |
41 (91.1) |
|
Yes |
4 (8.9) |
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