Organization of follow-up and transition of patients with gastrointestinal malformations

Due to the significant long-term morbidity, children with congenital malformations of the gastrointestinal tract are considered chronically ill patients. Therefore, they require lifelong and specialized medical follow-up care. In the vulnerable phase of transition to adulthood, many adolescents lose the connection to the specialized care. This interruption of follow-up care can be associated with increased morbidity. Therefore, the transition to adult medicine requires a systematic organization in order to avoid negative medical consequences for the patient as well as health economic disadvantages. In this article the challenges and possibilities of aftercare and transition of this special patient collective are highlighted. Particular attention is paid to patients with anorectal malformations, Hirschsprung's disease, esophageal atresia and short bowel syndrome. Due to the lack of a standardized transition processes, many essential medical and psychosocial aspects of those affected may be lost during the transition phase. Cooperative transition concepts with participation of pediatricians and adult physicians are mandatory to ensure the continuous care of chronically ill adolescents. Important elements are written transition reports, joint transition outpatient clinics and multidisciplinary case conferences. A structured transition and follow-up program for gastrointestinal congenital malformations ensures the continuation of interdisciplinary care into adult medicine. Ideally, a structured case management accompanies these programs. Thereby, the state of health as well as patient satisfaction can be maintained and improved in the long-term.