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Ye S, Feng W, Zhou Y, Ming A, Chen M, Yang C, Zheng C, Gao R, Diao M, Wang Y, Li L. Laparoscopic-assisted anorectoplasty for anorectal malformation with rectobulbar fistula: A two-center comparative study with posterior sagittal anorectoplasty. Medicine (Baltimore) 2023; 102:e35825. [PMID: 37986398 PMCID: PMC10659725 DOI: 10.1097/md.0000000000035825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 10/05/2023] [Accepted: 10/06/2023] [Indexed: 11/22/2023] Open
Abstract
Due to the controversy on the feasibility of laparoscopic-assisted anorectoplasty (LAARP) for the treatment of the anorectal malformation (ARM) with rectobulbar fistula (RBF), this study aimed to compare the outcomes of LAARP and posterior sagittal anorectoplasty (PSARP) for ARM with RBF. Demographic data, postoperative complications, and bowel function of RBF patients who underwent LAARP and PSARP at 2 medical centers from 2016-2018 were retrospectively reviewed. Eighty-eight children with RBF were enrolled, including 43 in the LAARP group and 45 in the PSARP group. There were no significant differences in the sacral ratio (P = .222) or sacral agenesis (P = .374). Thirty-seven and 38 patients in the LAARP and PSARP groups were followed up for a median of 4.14 years. The postoperative complications were comparable between the groups (P = .624), with no cases of urethral diverticulum. The urination of all cases was normal and no evidence of cyst formation was found on MCU or MRI during the follow-up period. The incidence of rectal prolapse was similar between the 2 groups (9.3% vs 17.8%, P = .247). The groups had equivalent Bowel Function Score (15.29 ± 2.36 vs 15.58 ± 2.88, P = .645), but the LAARP group had better voluntary bowel movement (94.6% vs 84.2%, P = .148) by Krickenbeck classification. The intermediate-term outcomes of LAARP show that the urethral diverticulum was rare by the intraluminal incision of the fistular and the bowel function was comparable to that of PSARP in ARM with rectobulbar fistula. However, LAARP was associated with smaller perineal wounds.
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Affiliation(s)
- Shiru Ye
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, People’s Republic of China
| | - Wei Feng
- Department of General & Neonatal Surgery, Children’s Hospital of Chongqing Medical University; National Clinical Research Center for Child Health and Disorders; Ministry of Education Key Laboratory of Child Development and Disorders; Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Yan Zhou
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, People’s Republic of China
| | - Anxiao Ming
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, People’s Republic of China
| | - Minming Chen
- Department of General & Neonatal Surgery, Children’s Hospital of Chongqing Medical University; National Clinical Research Center for Child Health and Disorders; Ministry of Education Key Laboratory of Child Development and Disorders; Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Changzhen Yang
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, People’s Republic of China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
- Research Unit of Minimally Invasive Pediatric Surgery on Diagnosis and Treatment(2021RU015), Chinese Academy of Medical Sciences, Beijing, China
| | - Chen Zheng
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, People’s Republic of China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
- Research Unit of Minimally Invasive Pediatric Surgery on Diagnosis and Treatment(2021RU015), Chinese Academy of Medical Sciences, Beijing, China
| | - Ruyue Gao
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, People’s Republic of China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
- Research Unit of Minimally Invasive Pediatric Surgery on Diagnosis and Treatment(2021RU015), Chinese Academy of Medical Sciences, Beijing, China
| | - Mei Diao
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, People’s Republic of China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
- Research Unit of Minimally Invasive Pediatric Surgery on Diagnosis and Treatment(2021RU015), Chinese Academy of Medical Sciences, Beijing, China
| | - Yi Wang
- Department of General & Neonatal Surgery, Children’s Hospital of Chongqing Medical University; National Clinical Research Center for Child Health and Disorders; Ministry of Education Key Laboratory of Child Development and Disorders; Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Long Li
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, People’s Republic of China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
- Research Unit of Minimally Invasive Pediatric Surgery on Diagnosis and Treatment(2021RU015), Chinese Academy of Medical Sciences, Beijing, China
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Tirrell TF, McNamara ER, Dickie BH. Reoperative surgery in anorectal malformation patients. Transl Gastroenterol Hepatol 2021; 6:43. [PMID: 34423164 DOI: 10.21037/tgh-20-214] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 06/24/2020] [Indexed: 11/06/2022] Open
Abstract
Currently accepted primary repair of congenital anorectal malformations (ARMs) includes a posterior sagittal incision, which allows for optimal visualization and identification of important pelvic structures and anatomical features. Reconstructive surgery involves meticulous dissection and separation of pelvic structures, and careful reconstruction can result in good functional outcomes for many patients, who live without ongoing sequelae from their malformation. However, some patients may require reoperative procedures for anatomic or functional reasons. Males and females present with slightly different symptoms and should be approached differently. Males are most likely to require reoperations for anorectal or urethral pathologies, but the urinary system is often spared in females-they instead must contend with Mullerian duct anomalies, of which there are many varieties. Depending on the original malformation and severity of symptoms, redo surgery may be needed to optimize function and quality of life. Surgical management with reoperative surgery in ARMs ranges from straightforward to complex, depending on the issue. One must weigh the risks of reoperative surgery and potentially creating more scarring against the need for a better anatomical and functional outcome. Current management trends and practice patterns with regards to reoperative surgery in ARM patients are not widely studied or standardized but we provide an overview of the more common pathologies, preoperative evaluation and workup required to identify the issues, and options for reoperative repair in these patients.
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Affiliation(s)
| | - Erin R McNamara
- Department of Urology, Boston Children's Hospital, Boston, MA, USA
| | - Belinda H Dickie
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
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Ishimaru T, Kawashima H, Hayashi K, Omata K, Sanmoto Y, Inoue M. Laparoscopically assisted anorectoplasty-Surgical procedures and outcomes: A literature review. Asian J Endosc Surg 2021; 14:335-345. [PMID: 33029900 DOI: 10.1111/ases.12877] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/08/2020] [Accepted: 09/22/2020] [Indexed: 11/27/2022]
Abstract
Anorectal malformation includes various types of anomalies. The goal of definitive surgery is achievement of fecal continence. Twenty years have passed since laparoscopically assisted anorectoplasty (LAARP) was reported by Georgeson. Since LAARP is gaining popularity, its long-term outcomes should be evaluated. Presently, there is no evidence regarding the optimal method of ligating and dividing the fistula correctly and creating the pull-through canal accurately. Rectal prolapse and remnant of the original fistula (ROOF) tend to develop more often in LAARP patients than in posterior sagittal anorectoplasty (PSARP) patients; however, robust evidence is not available. Prolapse may be prevented by suture fixation of the rectum to the presacral fascia; however, if prolapse occurs, the indication, timing, and the best method for surgical correction remain unclear. Most patients with ROOF are asymptomatic, and there is controversy regarding the indications for ROOF resection. This article aimed to detail the various modifications of the LAARP procedures reported previously and to describe the surgical outcomes, particularly focusing on rectal prolapse, ROOF, and fecal continence, by reviewing the literature. Functional outcomes after LAARP were almost similar to those noted after PSARP, and we have demonstrated that LAARP is not inferior to PSARP with respect to fecal continence. Although there is controversy regarding the application of LAARP for recto-bulbar cases, we believe that LAARP is still evolving, and we can achieve better outcomes by improving the procedure.
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Affiliation(s)
- Tetsuya Ishimaru
- Division of Pediatric Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Hiroshi Kawashima
- Division of Pediatric Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Kentaro Hayashi
- Division of Pediatric Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Kanako Omata
- Division of Pediatric Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Yohei Sanmoto
- Division of Pediatric Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Maho Inoue
- Division of Pediatric Surgery, Saitama Children's Medical Center, Saitama, Japan
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Ralls M, Thompson BP, Adler B, Ma G, Bates DG, Kraus S, Jarboe M. Radiology of anorectal malformations: What does the surgeon need to know? Semin Pediatr Surg 2020; 29:150997. [PMID: 33288131 DOI: 10.1016/j.sempedsurg.2020.150997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Imaging is extremely important throughout all phases of care provided to children with anorectal malformations (ARM). A preoperative determination of the patient specific malformation will help establish the operative plan. Moreover, the majority of ARM patients will have an associated anomaly that will require imaging workup for full understanding of those abnormalities prior to addressing the ARM. The complexity of ARM care will mandate continued imaging throughout the post-operative period even in those with straight forward malformations.
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Affiliation(s)
- Matthew Ralls
- Mott Children's Hospital, Ann Arbor, MI, United States.
| | | | - Brent Adler
- Nationwide Children's Hospital, Columbus, OH, United States
| | - Grace Ma
- Children's National Hospital, Washington, DC, United States
| | | | - Steve Kraus
- Cincinnati Children's Hospital, Cincinnati, OH, United States
| | - Marcus Jarboe
- Mott Children's Hospital, Ann Arbor, MI, United States
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Abstract
The introduction of posterior sagittal anorectoplasty (PSARP) by deVries and Peña in the early 80s has impacted to the treatment of patients with anorectal malformations (ARM). It gained great recognition worldwide in a very short time, and since then, surgeons dealing with the treatment of this complex malformation could achieve tremendous progress in contemporary management of this anomaly. Despite the growing experience and body of information globally, the treatment of ARMs continues to be a challenge to the pediatric surgeons due to the nature and the variability of the anomaly, and short- and long-term problems continue to exist even after nearly 40 years of the PSARP era. Today, knowing more about it, pediatric surgeons are committed to do more for their ARM patients to have them as physically and socially healthy individuals.
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Rentea RM, Halleran DR, Vilanova-Sanchez A, Lane VA, Reck CA, Weaver L, Booth K, DaJusta D, Ching C, Fuchs ME, Jayanthi RR, Levitt MA, Wood RJ. Diagnosis and management of a remnant of the original fistula (ROOF) in males following surgery for anorectal malformations. J Pediatr Surg 2019; 54:1988-1992. [PMID: 30879755 DOI: 10.1016/j.jpedsurg.2019.02.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 01/19/2019] [Accepted: 02/03/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE A complication of the surgical management of anorectal malformations (ARMs) is a retained remnant of the original fistula (ROOF) formerly called a posterior urethral diverticulum (PUD). A ROOF may have multiple presentations or may be incidentally discovered during the work-up of ARM after previous surgery. We sought to define the entity and the surgical indications for excision of a ROOF when found. METHODS We performed a retrospective cohort study of all male patients who presented to our center following previous repair for ARM at another institution, who came for evaluation of problems with urinary and/or fecal continence, from 2014 to 2017. Charts were reviewed for symptoms, original type of malformation, preoperative imaging, treatment, and postoperative follow-up. RESULTS Of 180 referred male patients, 16 had a ROOF. 14 underwent surgical repair to address this and for other redo indications, and 2 did not require intervention. 13 patients had an additional reason for a redo such as anal mislocation or rectal prolapse. Indications for ROOF excision were urinary symptoms (e.g. UTI, dribbling, passage of mucous via urethra, stone formation), to make a smoother posterior urethra for intermittent catheterization, or for prophylactic reasons. Patients were repaired at an average age of 4.2 years, using a PSARP only approach with excision of the ROOF for all except one patient who needed a laparotomy due to abdominal extension of the ROOF. No patient needed a colostomy. The original ARM repairs of the patients were PSARP (9), laparoscopic assisted (4) and abdominoperineal pullthrough (3). Preoperative evaluation included pelvic MRI, VCUG, and cystoscopy. The ROOF was visualized on 14 of 16 MRIs, 10 of 14 VCUGs, and 14 of 15 cystoscopies. Urinary symptoms associated with a ROOF and ease of catheterization were improved in all repaired cases. CONCLUSION Patients not doing well from a urinary or bowel standpoint post ARM pull-through need a complete evaluation which should include a check for a ROOF. Both modalities MRI and cystoscopy are needed as a ROOF can be missed on either alone. A VCUG was not reliable in identifying a ROOF. Excision is needed in patients to improve urinary symptoms associated with these lesions and to minimize the small but theoretical oncologic risk present in a ROOF. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Rebecca M Rentea
- Center for Colorectal and Pelvic Reconstruction-Nationwide Children's Hospital, Columbus, OH 43205, USA; Children's Mercy Hospital-Kansas City, Kansas City, MO 64108, USA.
| | - Devin R Halleran
- Center for Colorectal and Pelvic Reconstruction-Nationwide Children's Hospital, Columbus, OH 43205, USA
| | | | - Victoria A Lane
- Center for Colorectal and Pelvic Reconstruction-Nationwide Children's Hospital, Columbus, OH 43205, USA
| | - Carlos A Reck
- Center for Colorectal and Pelvic Reconstruction-Nationwide Children's Hospital, Columbus, OH 43205, USA
| | - Laura Weaver
- Center for Colorectal and Pelvic Reconstruction-Nationwide Children's Hospital, Columbus, OH 43205, USA
| | - Kristina Booth
- Center for Colorectal and Pelvic Reconstruction-Nationwide Children's Hospital, Columbus, OH 43205, USA
| | - Daniel DaJusta
- Center for Colorectal and Pelvic Reconstruction-Nationwide Children's Hospital, Columbus, OH 43205, USA
| | - Christina Ching
- Center for Colorectal and Pelvic Reconstruction-Nationwide Children's Hospital, Columbus, OH 43205, USA
| | - Molly E Fuchs
- Center for Colorectal and Pelvic Reconstruction-Nationwide Children's Hospital, Columbus, OH 43205, USA
| | - Rama R Jayanthi
- Center for Colorectal and Pelvic Reconstruction-Nationwide Children's Hospital, Columbus, OH 43205, USA
| | - Marc A Levitt
- Center for Colorectal and Pelvic Reconstruction-Nationwide Children's Hospital, Columbus, OH 43205, USA
| | - Richard J Wood
- Center for Colorectal and Pelvic Reconstruction-Nationwide Children's Hospital, Columbus, OH 43205, USA
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Lane VA, Skerritt C, Wood RJ, Reck C, Hewitt GD, McCracken KA, Jayanthi VR, DaJusta D, Ching C, Deans KJ, Minneci PC, Levitt MA. A standardized approach for the assessment and treatment of internationally adopted children with a previously repaired anorectal malformation (ARM). J Pediatr Surg 2016; 51:1864-1870. [PMID: 27554917 DOI: 10.1016/j.jpedsurg.2016.07.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 07/25/2016] [Accepted: 07/26/2016] [Indexed: 11/26/2022]
Abstract
INTRODUCTION A significant number of internationally adopted children have congenital birth defects. As a specialist center for colorectal diagnoses, we evaluate such children with an anorectal malformation (ARM) and have found that a significant number need a reoperation. Knowledge of the common complications following ARM surgery has led us to develop treatment algorithms for patients with unknown past medical and surgical history, a situation typically encountered in the adopted population. METHODS The results of investigations, indications, and rate of reoperation were assessed for adopted children with an ARM evaluated between 2014 and 2016. RESULTS 56 patients (28 males) were identified. 76.8% required reoperative surgery. Mislocation of the anus outside the sphincter complex was seen in 50% of males and 39.3% of females. Anal stricture, rectal prolapse, retained vaginal septum, and a strictured vaginal introitus were also common. CONCLUSION The reoperative surgery rate in the internationally adopted child with an ARM is high. Complete, systematic evaluation of these children is required to identify complications following initial repair. Development of mechanisms to improve the primary surgical care these children receive is needed.
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Affiliation(s)
- Victoria A Lane
- Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, Columbus, OH, USA.
| | - Clare Skerritt
- Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, Columbus, OH, USA.
| | - Richard J Wood
- Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, Columbus, OH, USA.
| | - Carlos Reck
- Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, Columbus, OH, USA.
| | - Geri D Hewitt
- Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, Columbus, OH, USA; Section of Gynecology, Nationwide Children's Hospital, Columbus, OH, USA.
| | - Kate A McCracken
- Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, Columbus, OH, USA; Section of Gynecology, Nationwide Children's Hospital, Columbus, OH, USA.
| | - Venkata R Jayanthi
- Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, Columbus, OH, USA; Section of Urology, Nationwide Children's Hospital, Columbus, OH, USA.
| | - Daniel DaJusta
- Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, Columbus, OH, USA; Section of Urology, Nationwide Children's Hospital, Columbus, OH, USA.
| | - Christina Ching
- Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, Columbus, OH, USA; Section of Urology, Nationwide Children's Hospital, Columbus, OH, USA.
| | - Katherine J Deans
- Center for Outcomes Research (CSOR), Nationwide Children's Hospital, Columbus, OH, USA.
| | - Peter C Minneci
- Center for Outcomes Research (CSOR), Nationwide Children's Hospital, Columbus, OH, USA.
| | - Marc A Levitt
- Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, Columbus, OH, USA.
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Abstract
BACKGROUND Anorectal malformation is a complex anomaly with a broad variety of expressions. There are different techniques available for correction of the anomaly, all with their specific morbidity. Recently, much attention has been paid to acquired posterior urethral diverticulum after correction of anorectal malformation. The aim of this retrospective study was to reappraise the laparoscopic approach to correction of the anorectal malformation with respect to what can be prevented and what can be improved. METHODS Between July 2000 and July 2011, a total of 19 boys born with a high or intermediate anorectal malformation were admitted to our center. All patients underwent a diagnostic workup and were included in the follow-up protocol. Follow-up continence was scored according to the Krickenbeck criteria. Patients were also invited for an ultrasound and micturition cystourethrogram (MCUG) at follow-up to determine or exclude the presence of a posterior urethral diverticulum. RESULTS All patients underwent a successful laparoscopy-assisted anorectal pull-through. Mean age at the time of surgery was 2.5 months. Mean length of hospital stay was 5 days. Mean follow-up was 73 months. Complications were encountered in six patients. At follow-up 53 % of all our patients had spontaneous bowel movements and 41 % needed the help of laxatives or rectal washouts. In three patients a residual blind ending fistula was determined on MCUG but there was no true diverticulum. CONCLUSION Correction of anorectal malformation is a complex procedure with significant morbidity. Refinements of the technique may prevent complications and improve outcome in both the laparoscopic and posterior sagittal anorectoplasty. Acquired posterior urethral diverticulum does not necessarily need to occur more often with the laparoscopic approach.
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Méndez-Gallart R, Rodríguez-Barca P, Estévez-Martínez E, García-Palacios M, Bautista-Casasnovas A. Urinary retention in an infant caused by a posterior urethral diverticulum lithiasis following surgery for anorectal malformation. Urolithiasis 2014; 42:183-5. [PMID: 24493407 DOI: 10.1007/s00240-014-0642-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 01/24/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Roberto Méndez-Gallart
- Department of Pediatric Surgery & Urology, Hospital Clínico University Hospital of Santiago, 15716. Avda. Choupana s/n., Santiago de Compostela. A Coruña, Spain,
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Podberesky DJ, Towbin AJ, Eltomey MA, Levitt MA. Magnetic Resonance Imaging of Anorectal Malformations. Magn Reson Imaging Clin N Am 2013; 21:791-812. [DOI: 10.1016/j.mric.2013.04.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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