• **Support groups and quality of life**

The importance of active involvement of family members and the patient itself is well recognized, but not always available. Parents must cope with the difficulty of accepting and adjusting to their child's condition, coordinate appointments with different healthcare providers, find information about their child's malformations, manage the financial demands of long-term medical care, and locate appropriate care centers [21,22]. Factors such as low income, socially disadvantaged groups, and inaccessible educational materials due to rarity of the malformations, limited access to information or lack of support groups can negatively influence adherence to the treatment plan. Quality of life in patients with CDS is unreported but it is known the long-term impact of incontinence and sexual dysfunction in patients with anorectal malformations. Spinal malformations such as myelomeningocele can lead to lower limb paralysis. The goal of management plan is to reduce disability early on by implementing bowel management programs in cases with low continence potential and the need for robust transitional care arrangements to enable continued management in adulthood [19,23]. The process of transition should start in early adolescence and the adult care provider who will assume care of the patient should be identified early in the process, when possible [3].

Our literature review has numerous limitations which influence the value and objectivity in making recommendations. We are aware of the difficulty of extracting consistent data and providing statistically significant results. There is a high heterogeneity in data reporting in case reports or case series articles, with ambiguous nomenclature used to describe the anatomy or details regarding surgical procedures and incomplete information about the extent of multi-organ malformations. The term "caudal duplication syndrome" was introduced in 1993, but there still are inconsistent ways of naming it (e.g., cloacal duplication).

#### **5. Conclusions**

Caudal duplication syndrome should receive more attention from the pediatric surgical community regarding team approach and data collection. It is not sufficient to report the anatomical particularities of a case. Similar to other rare and complex malformations which affect the caudal region and have an impact on the quality of life (for example, bladder exstrophy or cloacal exstrophy), patients with caudal duplication syndrome deserve a better integrated care to improve outcomes.

**Author Contributions:** Conceptualization, S.R.-I. and C.C.; methodology, I.D.-A. and S.D.; software, T.L.F.; validation, S.D. and I.M.; formal analysis, I.M.; investigation, I.D.-A. and S.D.; resources, S.R.-I.; data curation, C.C. and I.M.; writing—original draft preparation, I.D.-A. and C.C.; writing—review and editing, A.A.; visualization, A.A.; supervision, T.L.F.; project administration, S.R.-I. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Conflicts of Interest:** The authors declare no conflict of interest.
