Long-term results of anterior sagittal anorectoplasty for the treatment of vestibular fistula

Erudition from primary posterior sagittal anorectoplasty for anorectal malformations over two decades

PURPOSE

Perioperative and early post-operative outcomes of Primary Posterior sagittal anorectoplasty (P-PSARP) were evaluated.

METHOD

Retrospective analysis of cases who underwent P-PSARP from 2004 to 2019 was done. Perioperative care, management, complications, voluntary bowel movement, soiling and constipation, graded by Krickenbeck criteria were studied.

RESULTS

One hundred fifty six patients (134 girls) underwent P-PSARP at median age of 5 months (3 months to 14 years) in girls and 5(1-10) days in 21 boys. One male cloaca was operated at 5 months age. Of 20 boys, 5, 8, 4, 3 had rectobulbar urethral fistula, rectoprostatic urethral fistula, bladder neck fistula and male cloaca. Girls had vestibular fistula, rectovaginal fistula, vulval anus, anterior ectopic anus, pouch perineal fistulae and posterior anus with H type fistula in 114, 7, 6, 5, 1 and 1. Complications included wound infection, excoriation, oedema, mucosal prolapse, anal stricture, anal retraction and mortality in 6, 4, 5, 4, 4, 1 and 1, respectively. 35/155(12 neonates) required postoperative dilatations for 5(1-12) months. At follow-up, 96/114(84.2%) had voluntary bowel movements. 46/155 (29.7%) and 9/155 had constipation and soiling. 32:14:0 had grade 1:2:3 constipation, treated with diet (grade 1) and laxatives (grade 2) respectively. 4:3:2 had grade 1:2:3 soiling for initial 3 months, treated with bowel management programme.

CONCLUSION

P-PSARP is feasible, subject to proper case selection and good perioperative care, once learning curve is achieved.

Change over time in the postoperative defecation function in female patients with anovestibular fistula at a single institution: focus on the comparison of anal transposition with anterior sagittal anorectoplasty

PURPOSE

Anovestibular fistula (AVF) is the most common type of ARM in female patients. The present study investigated changes over time in the postoperative defecation function of female patients with AVF.

METHODS

Patient data were collected from 1984 to 2021. Eighty-eight female patients with AVF were enrolled. Patients' characteristics and the long-term outcome of defecation function were reviewed and analyzed retrospectively. The bowel function was evaluated according to the Japan Society of ARM Study Group evacuation score (ES).

RESULTS

Thirty-eight patients underwent anal transposition (AT), and 8 underwent anterior sagittal anorectoplasty (ASARP). The total evacuation score (ES) in AVF patients reached "excellent" at nine years old, regardless of the operative procedure. The constipation scores with AT showed better improvement than those with ASARP, but soiling scores in the ASARP group showed better improvement than those in the AT group. The postoperative complications did not affect the postoperative bowel function in AVF patients.

CONCLUSION

Most patients with AVF eventually achieved a satisfactory total ES. Given the difference in defecation score transition depending on the operative procedure or postoperative complications, it may be important to perform long-term defecation management via surgical procedures.

Effect of megarectum on postoperative defecation of female patients with congenital rectovestibular fistula or rectoperineal fistula

Background

To assess the effect of megarectum on postoperative defecation of female patients with congenital rectovestibular fistula or rectoperineal fistula.

Methods

From March 2013 to February 2021, 74 female patients with congenital rectovestibular fistula or rectoperineal fistula were treated. The age of patients ranged from 3 months to 1 year. Barium enema and spinal cord MRI were performed in all children. 4 patients were removed from the study because of spinal cord and sacral agenesis. Finally, 70 patients underwent one-stage anterior sagittal anorectoplasty (ASARP). Anal endoscopy and anorectal pressure measurement were performed 1 year after surgery. All patients were divided into two groups depending on the presence of megarectum (+) and (-) and observed for constipation and anal sphincter function.

Results

16 patients (4 months to 1 year) were complicated with megarectum, and 5 patients (3 months to 9 months) were without megarectum. The incision infection was seen in 3 patients. All patients were followed up for 1 year to 5 years. Fecal soiling was seen in 2 patients and constipation in 14 patients. Among 16 patients with megarectum, soiling was seen in 1 patient and the constipation in 12 patients. Among 54 patients without megarectum, soiling was seen in 1 patient and constipation in 2 patients. There was a significant difference in the incidence of postoperative constipation between the two groups (megarectum (+) 75% vs. megarectum (-) 3.7% (P < 0.05)). However, there was no significant difference in the score of anal sphincters between the two groups (P < 0.05). And there was no significant difference in anal resting pressure (P = 0.49) and length of anal high pressure area (P = 0.76). 7 patients with constipation and megarectum acquired normal anal function after the dilated rectum was resected.

Conclusion

Megarectum increases the possibility of difficult postoperative defecation in the patients with congenital rectovestibular fistula or rectoperineal fistula. However, constipation was not associated with ASARP postoperative effects on sphincter function. Resection of megarectum is helpful to the improvement of constipation.

Laparoscopic-Assisted Anorectoplasty for Rectovestibular Fistula: A Comparison Study with Anterior Sagittal Anorectoplasty

BACKGROUND

 Posterior or anterior sagittal anorectoplasty (ASARP) is the mainstream for correcting rectovestibular fistula (RVF). However, the intermediate RVF has the potential risk of wound complications when applying ASARP due to its high rectal pouch, long fistula tract, and difficulty separating the rectum and vagina. We developed laparoscopic-assisted anorectoplasty (LAARP) for surgical correction of RVF, which has acceptable preliminary outcomes. The purpose of this study is to evaluate the safety and efficacy of LAARP in comparison with ASARP for patients with RVF.

MATERIALS AND METHODS

 Twenty-five patients with RVF who underwent LAARP between October 2017 and December 2020 were retrospectively reviewed. The outcomes were compared with 43 patients who underwent ASARP between April 2015 and August 2018. The age, weight at operation, sacral ratio, operative time, and postoperative hospital stay were evaluated. The results were assessed for complications, perineum appearance, and bowel function.

RESULTS

 The two groups were comparable in terms of demographics. The median operative time of the LAARP group was significantly longer than that of the ASARP group (113 vs. 95 minutes; p = 0.015). The mean length of the resected rectum in the LAARP group was also longer than that in the ASARP group (6.75 ± 5.07 vs. 3.31 ± 3.06 cm; p = 0.001). Compared with the LAARP group, complications in the ASARP group were more frequent (4.0 vs. 27.9%, p = 0.036). No intraoperative or postoperative wound-related complications occurred in the LAARP group. However, in the ASARP group, one patient had an intraoperative vaginal injury and four had postoperative anastomosis-related complications. The incidence of redo operation in the ASARP group was significantly higher than that in the LAARP group (p = 0.000). Cosmetic satisfaction was higher in the LAARP group (96.0 vs. 76.7%; p < 0.05). In terms of voluntary bowel movement, soiling, and constipation, the LAARP group had similar results compare with the ASARP group.

CONCLUSION

 The LAARP technique has shown several unique strengths in treating intermediate type RVF, including lower risks of complications, and minimal muscular injury, with a comparable bowel function.

Single-stage procedures for anorectal malformations: A systematic review and meta-analysis

BACKGROUND

The purpose of this study is to describe all published studies of single-stage procedures for anorectal malformations and to perform a meta-analysis of studies that compared single-stage to staged procedures.

METHODS

Searches were conducted in Pubmed, Medline, Embase and CENTRAL. Meta-analysis was performed in RevMan and expressed as forest plots with odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

Thirty-eight studies were included in the narrative synthesis. Nine studies were included in the meta-analysis, representing 537 patients. The majority (70%) of patients included in this meta-analysis had either perineal or vestibular fistulas. Surgical site infection (SSI) was defined as any reported infection involving the neoanus (both superficial infection and dehiscence) and occurred in 51 of the 291 patients who underwent single-stage procedures, and 26 of the 244 patients who underwent staged procedure. Meta-analysis showed a 2.2 times higher risk of surgical site infection (SSI) amongst patients who undergo single-stage procedures (OR 2.22, 95% CI 1.26, 3.92). Six of the 293 patients (2%) who underwent single-stage procedures required a rescue ostomy for wound dehiscence. In LMIC the risk of wound dehiscence was three-fold higher in single-stage (36/202) compared to staged procedures (12/126) (OR 3.07, 95% CI 1.42, 6.63). In HIC there was no evidence of an increased risk of wound dehiscence in patients who underwent a single-stage (15/91) compared to a staged procedure (14/118) (OR 1.51, 95% CI 0.65, 3.51). There is no evidence of a difference between single-stage versus staged procedures with regards to functional outcomes including voluntary bowel movements (79/90 versus 111/128), soiling (24/165 versus 20/203) or constipation (27/90 versus 36/128).

CONCLUSION

This systematic review provides further evidence that single-stage procedures for selected patients with anorectal malformations are safe. Whilst there is evidence of an increased risk of SSI, this did not translate to a significant difference in long-term functional outcomes.

LEVELS OF EVIDENCE

Level II.

Bowel function and associated risk factors at preschool and early childhood age in children with anorectal malformation type rectovestibular fistula: An ARM-Net consortium study

BACKGROUND

Outcome of patients operated for anorectal malformation (ARM) type rectovestibular fistula (RVF) is generally considered to be good. However, large multi-center studies are scarce, mostly describing pooled outcome of different ARM-types, in adult patients. Therefore, counseling parents concerning the bowel function at early age is challenging. Aim of this study was to evaluate bowel function of RVF-patients at preschool/early childhood age and determine risk factors for poor functional outcome.

METHODS

A multi-center cohort study was performed. Patient characteristics, associated anomalies, sacral ratio, surgical procedures, post-reconstructive complications, one-year constipation, and Bowel Function Score (BFS) at 4-7 years of follow-up were registered. Groups with below normal (BFS < 17; subgroups 'poor' ≤ 11, and 'fair' 11 < BFS < 17) and good outcome (BFS ≥ 17) were formed. Univariable analyses were performed to detect risk factors for outcome.

RESULTS

The study included 111 RVF-patients. Median BFS was 16 (range 6-20). The 'below normal' group consisted of 61 patients (55.0%). Overall, we reported soiling, fecal accidents, and constipation in 64.9%, 35.1% and 70.3%, respectively. Bowel management was performed in 23.4% of patients. Risk factors for poor outcome were tethered cord and low sacral ratio, while sacral anomalies, low sacral ratio, prior enterostomy, post-reconstructive complications, and one-year constipation were for being on bowel management.

CONCLUSIONS

Although median BFS at 4-7 year follow-up is nearly normal, the majority of patients suffers from some degree of soiling and constipation, and almost 25% needs bowel management. Several factors were associated with poor bowel function outcome and bowel management.

LEVEL OF EVIDENCE

Level III.

Evaluation and management of "low" anorectal malformation in male children: an observational study

PURPOSE

ARM with perineal fistula has been traditionally defined as low ARM (LARM). This study was conducted to evaluate LARM in male patients with an emphasis on the role of various factors on the outcome and follow-up of them.

MATERIALS AND METHODS

It was a retrospective cohort study. The clinical presentation, associated anomalies, and complications were assessed. The operative procedures included cutback anoplasty and others. The patients were followed in the outpatient department. The complications were assessed and managed accordingly.

RESULTS

During the study period of 8 years, 301 patients were admitted. The complaints included absent or abnormal anal opening, abdominal distension, constipation, and peritonitis. Most of the children (n = 214) presented in the neonatal period. The most common clinical presentation was the perineal fistula. The most common associated anomaly was urologic. Fourteen patients were referred from other centers after complications. The most common problem in follow-up was constipation.

CONCLUSION

LARM in male patients may have a diverse presentation. The associated anomalies need proper assessment. Awareness may avoid delayed presentation and unwanted complications. When managed by an expert, the condition can be effectively managed. Regular follow-up is important.

Delayed vs. early enteral feeding after repair of congenital recto-vestibular fistula: The effect on perineal wound healing

INTRODUCTION

congenital Recto vestibular fistula represents the commonest type of anorectal malformation in females. The treatment of this anomaly is mainly approached either through anterior or posterior sagittal ano-rectoplasty approach. Several perioperative factors may affect the outcome. One of major postoperative complications is the occurrence of wound infection. We aimed to study the effect of delayed vs. early enteral feeding on the occurrence of perineal wound infection (PWI) after repair of congenital recto vestibular fistula.

PATIENTS AND METHODS

Fifty-five infants with recto-vestibular fistula were included. They were managed by single stage anterior sagittal anorectoplasty (ASARP) at an age ≥3 months. Groups A and B included infants who started oral intake on the 6th and 2nd postoperative days respectively. Group A infants were kept on peripheral parenteral nutrition (PPN) during the fasting period.

RESULTS

Superficial wound infection occurred in three cases in group A while it developed in seven cases in group B. Deep perineal infection occurred in two and five cases in group A and group B respectively. The mean hospital stay was 8 days in group A vs. 13 days in group B when PWI developed.

CONCLUSION

Delayed enteral feeding with PPN keeps the perineal wound less contaminated with stool. This promoted proper and fast healing with lower incidence of PWI. Also, PPN compensates the catabolic effects of both surgical trauma and fasting during the postoperative period and ensures maintenance of normal levels of essential nutrients that allow for proper healing.

The early outcome of primary anterior sagittal approach for low anorectal malformations in female patients

Objective:

To document our experience of the primary anterior sagittal anorectoplasty (ASARP) in female patients with lower and wide fistula in term of the early post operative outcome.

Methods:

A retrospective descriptive study was conducted in one surgical unit of the National Institute of Child Health Karachi, from January 2010 to April 2018. The study included female patients with diagnosis of imperforate anus with wide Vestibular or Perineal fistula with minimal or no straining during defecation and no excoriation of perineum. All patients underwent primaryASARP. Data regarding the age of the patients, site of fistula, the difficulties in dissection, post operative complications, stoma and re-do ASARP needed, were documented. Wound assessment was done during hospital stay, at two weeks and then at three months after surgery. Outcome was documented in terms of complications of surgery and cosmetic appearance of perineum. Data was analyzed on SPSS version 20.

Results:

A total of 70 patients underwent primary surgery, 48(68.57%) females had perineal fistula while 22(31.42%) had vestibular fistula. Age ranges between three months to 276 months with median of 6±39.73 months. No major injury to the rectal or vaginal wall occurred during surgical procedure. In early post-operative period, 12(17.14%) patients had wound infection with or without various extent of disruption. A total of seven (10.11%) patients underwent stoma formation, six (8.57%) patients because of wound disruption with in a week of primary surgery and in one patient due to severe anal stenosis and retraction of anal segment within three month follow up. Median hospital stay was 5±1.52 days. In 38(54.28%) paients complete wound healing occurred with no per or post operative complications. In 25(35.71%) patients, minor complications were noted and treated accordingly and results were labelled satisfactory with acceptable perineal appearance.

Conclusion:

The single stage procedure can be a good choice for both vestibular and perineal fisula. In majority of cases wound heals completely with minimal or no scaring and give good cosmetic results.

Anterior Sagittal Anorectoplasty: Our Experience

Context

Anterior sagittal anorectoplasty (ASARP) is accepted as one of the techniques for the repair of vestibular fistula (VF) and low-type anomalies, but some may have reservations.

Aims

The aim of the study is to describe the technique, important features, and functional and cosmetic outcomes of ASARP for the treatment of anorectal malformation (ARM) in females.

Settings and Design

A prospective study was performed from 1992 to 2017.

Materials and Methods

The study included 157 pediatric patients (aged 1-15 years) with diagnosis of ARMs with VF, perineal fistula (perineal ectopic anus), and rectovaginal fistula managed by ASARP.

Results

Most cases (36.94%) were 1-6 months' age group; 92.99% of patients (146) were having VF, 5.09% (8) perineal fistula, and 1.91% (3) rectovaginal fistula. Associated anomalies (37) were present in 19.75% (31) of patients. Primary ASARP was performed in 85.35% (134) of cases. The mean operative time was 105 (±15) min. Intraoperative complications were seen in 3.82% (6) of patients. Early postoperative complications were seen in 5.09% (8) of patients - wound infection (4), wound dehiscence (3), and retraction of the rectum (1). Late complications were seen in 12.73% (20) of cases. Overall, five patients developed anal stenosis, two responded to dilatation therapy, and three required anoplasty. The external appearance of the perineum after the 3^rd month (postoperatively) was satisfactory in 95.54% (150); overall, 4.46% (7) of patients required the second procedure. Stooling pattern could be assessed in 80.25% (126) of patients at 3 years' age group. Only one had poor outcome with severe soiling (incontinence) and perineal excoriation that also had myelomeningocele.

Conclusions

ASARP is an excellent procedure for VF as it results in optimal correction with minimal sphincteric damage, without additional complexity or difficulties. Primary ASARP is a quick and effective technique and does not require colostomy if performed after due preoperative gut preparation and by an experienced pediatric surgeon.

Anterior sagittal anorectoplasty as a technique for the repair of female anorectal malformations: A twenty two-years-single-center experience

BACKGROUND

Anorectal malformations (ARMs) are major congenital malformations occurring in female children in approximately 1 out of every 4000-5000 births. Posterior sagittal anorectoplasty (PSARP) was introduced for their treatment in early 1980s by Pena and Devries. However, anterior sagittal anorectoplasty (ASARP) was first introduced by Okada as a modification of the previous technique.

PURPOSE

The aim of this study was to report our experience and the long-term follow-up results of 594 female patients with anorectal malformations treated by anterior sagittal anorectoplasty (ASARP) in a single center over 22 years. We chose this approach as the incision is smaller, with minimal cutting of the external sphincter and easier dissection of the vagina and rectum. The type of our study was retrospective study.

RESULTS

The study included 594 patients; 342 of them were less than 1 year old. About 526 patients had rectovestibular fistula, anterior perineal anus in 55 patients, anocutaneous fistula in 6 patients and rectovaginal fistula in 7 patients. All of these patients had been subjected to ASARP technique which had been done in one stage without proceeding colostomy in about 470 cases and in staged fashion with a protective colostomy in 124 patients. Postoperative follow up revealed that four patients (0.7%) developed anal retraction, 30 patients (5%) developed anal stricture, 20 patients (3.4%) had rectal prolapse and 40 patients (6.7%) developed anterior anal migration. Constipation was observed in 161 patients (27%) by the end of 1st postoperative year reduced to 41 patients (7%) after one year. 474 patients were assessed for continence by Kelly's continence score and 453 patients showed good result, 16 patients showed fair result and about 5 patients had poor continence outcome.

CONCLUSION

Anterior sagittal anorectoplasty is a procedure with optimal functional outcome especially at if done at an early age in one stage without preliminary colostomy.

The impact of perioperative care on complications and short term outcome in ARM type rectovestibular fistula: An ARM-Net consortium study

BACKGROUND

The impact of perioperative care interventions on postreconstructive complications and short-term colorectal outcome in patients with anorectal malformation (ARM) type rectovestibular fistula is unknown.

METHODS

An ARM-Net consortium multicenter retrospective cohort study was performed including 165 patients with a rectovestibular fistula. Patient characteristics, perioperative care interventions, timing of reconstruction, postreconstructive complications and the colorectal outcome at one year of follow-up were registered.

RESULTS

Overall complications were seen in 26.8% of the patients, of which 41% were regarded major. Differences in presence of enterostomy, timing of reconstruction, mechanical bowel preparation, antibiotic prophylaxis and postoperative feeding regimen had no impact on the occurrence of overall complications. However, mechanical bowel preparation, antibiotic prophylaxis ≥48 h and postoperative nil by mouth showed a significant reduction in major complications. The lowest rate of major complications was found in the group having these three interventions combined (5.9%). Multivariate analyses did not show independent significant results of any of the perioperative care interventions owing to center-specific combinations. At one year follow-up, half of the patients experienced constipation and this was significantly higher among those with preoperative mechanical bowel preparation.

CONCLUSIONS

Differences in perioperative care interventions do not seem to impact the incidence of overall complications in a large cohort of European rectovestibular fistula-patients. Mechanical bowel preparation, antibiotic prophylaxis ≥48 h, and postoperative nil by mouth showed the least major complications. Independency could not be established owing to center-specific combinations of interventions.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

III.

One-stage repair of anorectal malformations in females with vestibular fistula: a systematic review and meta-analysis

PURPOSE

Females with recto-vestibular fistula (RVF) can be managed either by one-stage sagittal anorectoplasty (SARP) or by conventional multi-stage approach with colostomy followed by SARP. Our aim was to define which approach, one-stage or multi-stage, is safer and more beneficial.

METHODS

Using a defined search strategy, two investigators identified all comparative studies on the mentioned procedures. The study was conducted under PRISMA guidelines. The meta-analysis was performed using RevMan 5.3. Data are mean ± SD.

RESULTS

Of 649 titles/abstracts screened, 13 full-text articles were analyzed. Three studies were included (156 females). One-stage SARP was associated with increased risk of wound infection (24.3 ± 8.7%) compared to multi-stage approach (10.9 ± 2.5%; p < 0.01) and increased risk of wound dehiscence (16.2 ± 4.8% vs. 2.4 ± 1.1%, respectively; p < 0.01). The incidence of anorectal stenosis was higher following one-stage repair (33.3%) vs. multi-stage approach (10.7%; p < 0.05). No differences were found with regards to redo SARP in both groups (12.9 ± 7.3% vs. 4.8 ± 0.8%; p = ns). At follow-up, the prevalence of soiling and constipation were similar after one-stage (19.7 ± 10.3% and 29.5 ± 5.4%) and multi-stage repair (13.7 ± 8.9% and 28.7 ± 4.4%; p = ns).

CONCLUSIONS

In females with RVF, the SARP performed without protective colostomy increases the risk of postoperative complications. However, this one-stage approach seems not to be associated with reduced fecal continence.

Investigation of the feasibility and safety of single-stage anorectoplasty in neonates with anovestibular fistula

PURPOSE

Anovestibular fistula (AVF) is the most common type of anorectal malformation in females. Delayed anorectoplasty with fistula dilatation is commonly performed during infancy; however, we have been actively performing anorectoplasty in neonates. We report the surgical complications and postoperative defecation function associated with single-stage anorectoplasty performed in neonates.

METHODS

Patients who underwent surgery for AVF between 2007 and 2017 at two institutions were retrospectively studied. The operation time, amount of bleeding, time to start oral intake, perioperative complications, and Kelly's score were compared among patients who underwent surgery as neonates and those who underwent surgery as infants.

RESULTS

Eighteen neonates and 17 infants underwent anterior sagittal anorectoplasty. The median operation time and time to start oral intake were significantly shorter in the neonatal group (72 min; 3 days, respectively) than in the infant group (110 min, p = 0.0002; 5 days, p = 0.0024, respectively). Postoperative wound disruption was significantly more frequent in the infant group. Of the ten patients each in the neonatal and infant groups, there was no significant difference in Kelly's score at age ≥ 4 years.

CONCLUSION

Single-stage anorectoplasty in neonates with AVF can be feasibly performed and does not impair postoperative defecation function.

LEVELS OF EVIDENCE

III.

Anorectal Malformations in Adolescent Females: A Retrospective Study

Context:

While most of the females with anorectal malformations (ARMs) present in either neonatal period or early infancy, a small percentage presents in their adolescence.

Aim:

The aim is to study the causes of delay in presentation, management, and postoperative outcome in these cases.

Settings and Design:

This is a retrospective observational study conducted in the Department of Paediatric Surgery, King George's Medical University, Lucknow.

Subjects and Methods:

Records of females with ARM managed in one unit of the department from 2010 to 2015 were scrutinized. Of these, record of females who primarily presented in adolescence was reviewed. Data regarding the demographics, clinicoradiological presentation, management, postoperative stay, and follow-up were analyzed. Causes for delay in presentation were looked for.

Statistical Analysis Used:

Statistical analysis used was not required.

Results:

Out of 627 cases of ARM managed over 5 years, ten girls (5.3%) presented between 12 and 18 years (average 14.4 years). Main reasons for the delay in presentation were misinformation, illiteracy, and poverty. These comprised of anovestibular fistula (n = 5), anterior ectopic anus (n = 3), perineal canal (n = 1), and rectovestibular fistula (n = 1). Three (30%) girls had no problem apart from an abnormal anal orifice. Five (50%) girls had constipation as a major additional symptom. Four cases had a normal to mildly enlarged rectum on contrast study, whereas the rectum was moderately to hugely dilated in the remaining six cases. Six cases were managed with posterior sagittal anorectoplasty while an anterior sagittal anorectoplasty was done in four. Minor wound dehiscence developed in two cases. There was no mortality. In a mean follow-up of 16 months (8–26), constipation and soiling were seen in 5 (50%) girls. The overall outcome in these girls was satisfactory.

Conclusion:

Presentation of females with ARM in adolescence is not uncommon in the third world. A primary pull through is possible in these girls with mild-to-moderate rectal dilatations. A diverting colostomy before pull through is always a safe option in cases with severely dilated rectum and also otherwise. Moreover, a greater awareness regarding these malformations in the general public is required.

Histology with immunohistochemistry of the fistula region in female anorectal malformation: Can it be used for neo-anus reconstruction?

AIM

Female anorectal malformation is characterised by communication to the exterior by a fistula. There are conflicting reports of the presence of normal anus in the fistula region. This study was undertaken to assess the histopathology and immunohistochemical correlation of the terminal portion of the fistula in female patients and suitability of fistula incorporation in the reconstruction of the neo-anus.

METHODS

This prospective study included 13 patients of female anorectal malformation. Of these, seven had a vestibular fistula (VF), and the rest had an anterior ectopic anus (AEA). Histopathology of the fistula region was undertaken, along with immunohistochemistry. Various findings were evaluated.

RESULTS

Of seven VF patients, four showed atrophic or disrupted internal sphincter smooth muscle, whereas the remaining three showed hypertropic internal sphincteric smooth muscle. Six patients showed hypertrophic nerve bundle. Five VF patients showed subepithelial fibrosis, and none of them showed ganglion cells. Of six patients of AEA, internal sphincteric smooth muscle was normal in five. It was hypertrophic in one patient. Transitional epithelium was present in four patients. All patients showed hypertrophic nerve bundle and aganglionosis. Subepithelial fibrosis was observed in six patients.

CONCLUSION

The fistula region in VF and AEA patients appears to be an abnormal structure. Rather than preservation of the terminal fistulous region, resection followed by anoplasty may be a viable option.

Functional assessment of the patients with perineal and vestibular fistula treated by anterior sagittal anorectoplasty

BACKGROUND

Anterior sagittal anorectoplasty (ASARP) has been a standardised operative treatment for anorectal malformation (ARM). This retrospective study was undertaken to evaluate patients with perineal fistula (PF) and vestibular fistula (VF) treated by ASARP in our institution.

PATIENTS AND METHODS

Twenty patients (PF, n = 14; male, n = 8 and female, n = 6 and VF, n = 6) were evaluated. Eighteen patients underwent primary ASARP without protective colostomy. Two patients underwent colostomy because of intestinal atresia and suspected of other type ARM. The age range of operation was from 4 months to 5.0 years. Sixteen patients (PF, n = 13; male, n = 7 and female n = 6 and VF, n = 3) over 3 years of age were evaluated according to the Krickenbeck classification.

RESULTS

Operative complications occurred in one patient. Minor wound dehiscence occurred in six patients. Mucosal prolapse occurred in two patients. According to the Krickenbeck classification, amongst male patients with PF, all patients had voluntary bowel movements (VBMs) and two patients had Grade 1 soiling, while four patients had Grade 2 constipation. Amongst female patients with PF, all patients had VBM and no soiling, one patient had Grade 1 and two patients had Grade 2 constipation. In patients with VF, one patient was continent with Grade 1 soiling. One patient had Grade 2 and two patients had Grade 3 constipation.

CONCLUSIONS

ASARP without colostomy carried a risk of wound dehiscence. The ASARP technique provided normal or moderate outcomes for VBM and soiling. However, in about half of patients, defecation management with laxative therapy was required to achieve a normal condition.

Anterior Sagittal Anorectoplasty with External Sphincter Preservation for the Treatment of Recto-vestibular Fistula: A New Approach

Context

To our knowledge, there is no description of anterior sagittal anorectoplasty (ASARP) with external anal sphincter preservation and passing neorectum in the middle of muscle complex under direct vision for the treatment of recto-vestibular fistula (VF).

Aim

This study evaluates a new modification combining ASARP with under vision sphincter preservation.

Subjects and Methods

This prospective study was conducted on thirty female infants with VF. Procedure starts with a vertical midline incision extending from ectopic opening to posterior limit of external sphincter. Sharp dissection of the fistula is carried out. Artery forceps is passed at the center of muscle complex under vision, then neorectum is placed in the middle of the muscle complex. We introduced a new scoring system based on parental interview assessing functional outcome. Each patient was given a score between 0 and 20; good: 14-20, fair: 7-13, and poor: 0-6.

Results

ASARP was performed at a mean age of 2.6 months, a mean weight of 5.2 kg, a mean operative time of 102 min, and a mean hospital stay of 3.6 days. Wound infection occurred in four cases, seven cases had perianal excoriations, six cases had anal stenosis, and only one case complained of anal displacement. Patients followed for a mean of 18.8 months. Majority of our patients (50%) had good score (mean = 16.8), normal frequency, no or mild soiling, normal anal position with no or mild stenosis. Fourteen patients had fair score (mean = 10.5). Only one had poor outcome with severe soiling and perineal excoriation.

Conclusion

Our modification offers optimal correction, with minimal sphincteric damage, without additional complexity or difficulties. Scoring system is simple, practical, and truly reflects early functional and parent satisfaction after surgery.

Long-term bowel function, quality of life and sexual function in patients with anorectal malformations treated during the PSARP era

Anorectal malformations are an important group of congenital anomalies that vary widely in their anatomical characteristics and complexity. Understanding the long-term functional outcomes after modern treatments, and how these compare to the general population, are essential for ensuring that patients receive optimal, evidence-based care. With increasing appreciation of the wider impact of the illness on patients and their families, minimizing social disability from fecal incontinence and enabling normal social integration from the outset are key management concerns. This review summarizes the current knowledge on the functional outcomes by type of malformation, reflecting on the literature, and our institutional experience over a follow-up period of nearly 30 years.

Controversy of Single versus Staged Management of Anorectal Malformations

Anorectal malformations' (ARMs) management has taken strides over the past few decades. The advent of Posterior sagittal anorectoplasty (PSARP) and its acceptance by most people across the globe as standard procedure has given way to a debate of single vs. three-staged repair. After initial hesitancy and lot of skepticism, single-staged repair has very well established its role because of its advantages over the staged procedure. There is enough evidence which suggests that single-staged repair has got equally good outcome as that of staged repair (if not better). Further, one-staged repair offers advantages of lesser morbidity, lesser cost, and lesser burden to the family. The initially thought disadvantages of higher chances of injuries, wound infection and stress to neonates have been countered by growing evidences. The authors agree that staged procedure will continue to stay around for few specific indications like perforation peritonitis, extreme prematurity and special anatomical entities. Further, it can have more important role with advent of laparoscopy and better health infrastructure in future. But with new developments in imaging, scopes and neonatal care, single-staged repair is a feasible and safe modality for treatment of these anomalies.

Posterior sagittal anorectoplasty in vestibular fistula: with or without colostomy

PURPOSE

The aim of this study is to compare the results and complications of one- and three-stage repairs in females with vestibular fistula (VF) and make contribution to the discussion of whether the disadvantages outweigh the protective effect of a colostomy from wound infection and wound dehiscence following posterior sagittal anorectoplasty (PSARP).

METHODS

Patients with a diagnosis of VF who underwent PSARP between October 2009 and November 2015 were retrospectively reviewed. The patients were divided into two groups: Group 1-patients treated by one-stage procedure (n = 30); Group 2-patients treated by three-stage procedure (n = 16).

RESULTS

There were no statistically significant differences between the groups with respect to wound infection, recurrence of fistula and rectal mucosal prolapse. Minor wound dehiscence occurred slightly more common in Group 1, even if p value is not significant. No wound dehiscence has been observed since we switched to the protocol of keeping the child nil per oral for 5 postoperative days and loperamide (0.1 mg/kg) administration for 7 postoperative days. The mean time before resuming oral intake was 2.87 ± 1.7 and 1.19 ± 0.4 days in Group 1 and Group 2, respectively (p = 0.001). None developed major wound disruption or anal stenosis in either group. There were no statistical differences between the groups in terms of voluntary bowel movements, soiling and constipation.

CONCLUSIONS

PSARP performed without a protective colostomy in patients with VF has low morbidity, good continence rates and obvious advantages for both the patients and their parents.

Manometric findings in relation to functional outcomes in different types of anorectal malformations

AIMS

To compare anorectal manometry (AM) in patients with different types of anorectal malformations (ARMs) in relation to functional outcomes.

METHODS

A single-institution, cross-sectional study. After ethical approval, all patients ≥7years old treated for anterior anus (AA), perineal fistula (PF), vestibular fistula (VF), or rectourethral fistula (RUF) from 1983 onwards were invited to answer the Rintala bowel function score (BFS) questionnaire and to attend anorectal manometry (AM). Patients with mild ARMs (AA females and PF males) had been treated with minimally invasive perineal procedures. Females with VF/PF and males with RUF had undergone internal-sphincter saving sagittal repairs.

RESULTS

55 of 132 respondents (42%; median age 12 (7-29) years; 42% male) underwent AM. Patients with mild ARMs displayed good anorectal function after minimally invasive treatments. The median anal resting and squeeze pressures among patients with mild ARMs (60 cm H2O and 116 cm H2O respectively) were significantly higher than among patients with more severe ARMs (50 cm H2O, and 80cm H2O respectively; p≤0.002). The rectoanal inhibitory reflex was preserved in 100% of mild ARMs and 83% of patients with more severe malformations after IAS-saving sagittal repair. The functional outcome was poor in 4/5 patients with an absent RAIR (BFS≤11 or antegrade continence enema-dependence). Rectal sensation correlated significantly with the BFS.

CONCLUSIONS

Our findings support the appropriateness of our minimally invasive approaches to the management of mild ARMs, and IAS-saving anatomical repairs for patients with more severe malformations.

LEVEL OF EVIDENCE

III.

One or Two Stages Procedure for Repair of Rectovestibular Fistula: Which is Safer? (A Single Institution Experience)

BACKGROUND

Rectovestibular fistula (RVF) is the most common type of anorectal malformations in females. The need for a diverting colostomy during correction of defect has ignited a heated debate. In this study, we reviewed the girls with RVF that had been treated by either one or two stage procedure in the past 10 years in our institution to define whether one stage or two stage procedures is safer and more beneficial for the patients.

MATERIALS AND METHODS

Seventy girls with RVF that had been operated from January 2005 to January 2015 were studied retrospectively. Data were obtained from medical hospital records. The cases were divided into two groups. Group A (46 patients): were operated by two stages technique (simultaneous sigmoid colostomy and anterior sagittal anorectoplasty [ASARP]). Group B (24 patients): were operated by one stage (ASARP without covering colostomy). The short-term outcome as regard wound infection, wound dehiscence, anal stenosis, anal retraction, recurrence of fistula as well as complications of colostomy was reported. The long-term outcome as regard soiling, constipation and voluntary bowel movement was evaluated.

RESULTS

The age of patients at the time of surgery ranged from 3 months to 2 years (mean; 9.5 months). In Group A, seven patients (15.2%) developed wound infection, two patients developed wound disruption. One patient developed anterior anal retraction and required redo-operation, anal stenosis was noticed in five (10.9%) patients. Complications from colostomy had occurred in nine patients (19.5%). In Group B, wound infection occurred in ten patients (41.7%). Seven patients (29.2%) developed wound disruption. Anal stenosis occurred in eight patients (33.3%). Five patients required redo-operation because of anal retraction in three patients and recurrence of fistula in the other two patients. Constipation recorded in 15 patients (32.6%) of Group A and in ten patients (41.3%) of Group B. Soiling was reported in six girls (13.04%) of Group A and five girls (20.8%) of Group B.

CONCLUSION

The avoidance of colostomy is not outweighed achieving sound operation and continent child. Two stages correction of RVF is safer and more beneficial than one stage procedure, especially in our locality and for our paediatric surgeons during their learning curve.

Primary Definitive Procedure versus Conventional Three-staged Procedure for the Management of Low-type Anorectal Malformation in Females: A Randomized Controlled Trial

Introduction:

Females with Krickenbeck low-type anorectal malformations - vestibular fistula (VF) and perineal fistula (PF) - are managed either by a primary definitive or conventional three-staged approach. Ultimate outcome in these children may be affected by wound dehiscence leading to healing by fibrosis. Most of the literature favors one approach over other based on retrospective analysis of their outcomes. Whether a statistically significant difference in wound dehiscence rates between these approaches exists needed to be seen.

Materials and Methods:

A randomized controlled trial for girls <14 years with VF or PF was done. Random tables were used to randomize 33 children to Group I (primary procedure) and 31 to Group II (three-staged procedure). Statistical analysis was done for significance of difference (P < 0.05) in the primary outcome (wound dehiscence) and secondary outcomes (immediate and early postoperative complications).

Results:

Of the 64 children randomized, 54 (84%) had VF. Both groups were comparable in demography, clinical profile and age at surgery. The incidence of wound dehiscence (39.4% vs. 18.2%; P = 0.04), immediate postoperative complications (51.5% vs. 12.9%; P = 0.001), and early postoperative complications (42.4% vs. 12.9%; P = 0.01) was significantly higher in Group I as compared to Group II. Six of 13 children (46.2%) with dehiscence in Group I required a diverting colostomy to be made.

Conclusions:

Females with VF or PF undergoing primary definitive procedure have a significantly higher incidence of wound dehiscence (P = 0.04), immediate (P = 0.001) and early postoperative complications (P = 0.01).

Use of a Heineke-Mikulicz like stricturoplasty for intractable skin level anal strictures following anoplasty in children with anorectal malformations

INTRODUCTION

We introduced a modification of the Heineke-Mikulicz technique to treat intractable skin level anal strictures post posterior sagittal anorectoplasty (PSARP). The aim of this article is to describe the technique and outcome in a series of patients.

METHODS

This was a retrospective evaluation of patients who had Heineke-Mikulicz like stricturoplasty performed for a post PSARP skin level stricture over a one-year period.

RESULTS

Five patients who were operated using the technique were reviewed. All had severe anal strictures that could admit Hegar dilator sizes 6 to 9 at 16months to 5years after PSARP. All underwent routine dilatations, which became increasingly painful. As an alternative to continued dilatations, an operative procedure was offered. The surgery was done as a day case and lasted 10 to 30min. The anus at the end of the procedure could comfortably accept a Hegar dilator size 14 to 17. None of the patients had a colostomy after the procedure and there were no complications.

CONCLUSIONS

The Heineke-Mikulicz like stricturoplasty is a simple surgical procedure that can be done in an ambulatory setting to treat children with intractable skin level anal stricture if this develops following definitive surgery for anorectal malformations.

Unexpected megarectum: A potential hidden source of complications in patients with anorectal malformation

BACKGROUND

Primary posterior sagittal anorectoplasty is recommended to repair anorectal malformations with rectoperineal or rectovestibular fistula. The aim of this study was to identify the impact of the presence of megarectum on the relative frequency of complications related to posterior sagittal anorectoplasty.

METHODS

We performed a cross-sectional retrospective study including patients with anorectal malformation, preoperative rectogram and surgically treated with primary or staged posterior sagittal anorectoplasty. Only complications related to anorectoplasty were analyzed and compared with the presence of megarectum.

RESULTS

Thirty patients aged 1 day to 7 years were included, 60% had megarectum. Sixteen patients had primary repair: 6 with megarectum and 10 without megarectum; complications occurred in four of the six with megarectum, 66.7%, and no complication were observed in the 10 patients without megarectum (F p=0.008). Fourteen patients had staged repair and no complications related to posterior sagittal anorectoplasty occurred in these patients.

CONCLUSIONS

Comprehensive preoperative evaluation in patients with anorectal malformation with rectoperineal or rectovestibular fistula could include a rectogram. Awareness of the presence of megarectum could be useful information in the decision to create a colostomy or perform a primary posterior sagittal anorectoplasty.

Bowel functional outcomes in females with perineal or vestibular fistula treated with anterior sagittal anorectoplasty: controlled results into adulthood

BACKGROUND

Anterior sagittal anorectoplasty is a standardized operative treatment for females with congenital rectoperineal or vestibular fistula. The controlled, long-term outcomes require characterization.

OBJECTIVE

The aim of this study was to define the bowel functional outcomes following anterior sagittal anorectoplasty in relation to age- and sex-matched controls.

DESIGN

This cross-sectional study was conducted at a single institution.

PATIENTS

All females treated for congenital perineal or vestibular fistula with anterior sagittal anorectoplasty between 1983 and 2006 were invited to answer a detailed, previously validated questionnaire on bowel function. Each patient was matched to 3 controls who had answered identical questionnaires. Ethical approval was obtained. Social continence was defined as soiling or fecal accidents <1/week and no requirement for changes of underwear or protective aids.

SETTING

This study was conducted at the Hospital for Children and Adolescents, University of Helsinki, Finland.

INTERVENTIONS

No interventions were performed.

MAIN OUTCOME MEASURES

The primary outcomes measured were the prevalence of problems with rectal sensation, voluntary bowel control, soiling, fecal accidents, constipation, and social problems. Bowel function score (out of 20 items) was considered, as well as the age at completion of toilet training for stool.

RESULTS

Of 34 respondents (79%; median age, 13 (4-28) years), all had voluntary bowel movements. Problems withholding defecation, soiling, and fecal accidents were significantly more common among patients than controls (p ≤ 0.001). Eighty-five percent of patients and 100% of controls (p = 0.001) were socially continent; 41% of patients and 76% of controls were totally continent (p = 0.0003). Constipation tended to decline with age (from 59% to 25%; p = 0.16). The bowel functional outcome was good in 68% of patients, satisfactory in 26% of patients, and poor in 6% of patients. Diapers for stool had been discontinued at the same median age as controls.

LIMITATIONS

Number of patients in comparative analysis of symptoms by age group.

CONCLUSIONS

After anterior sagittal anorectoplasty for perineal or vestibular fistula, 2 of 3 of patients are likely to achieve bowel control comparable to normal in the long term, and the vast majority will be socially continent. The effective treatment of constipation is essential.

First results of a European multi-center registry of patients with anorectal malformations

BACKGROUND

The European consortium on anorectal malformations (ARM-NET) was established to improve the health care of patients and to identify genetic and environmental risk factors. The aim of the present study was to present the first results on clinical data of a large European cohort of ARM patients based on our registry.

METHODS

In 2010, the registry was established including patient characteristics and data on diagnosis, surgical therapy, and outcome regarding complications. Patients born between 2007 and 2012 were retrospectively added. A descriptive analysis of this cohort was performed.

RESULTS

Two hundred and three ARM patients were included. Syndromes or chromosomal abnormalities were present in 9%. Perineal fistulas were seen most in boys (42%) and girls (29%). Rare forms of ARM were found in 4% of the male and in 14% of the female patients. Forty-five percent of the patients had additional urogenital abnormalities. However, 32% of the patients were never screened for bladder abnormalities. Eight percent were never screened for renal malformations. In the majority of patients (79%), a PSARP was performed for the definitive reconstruction.

CONCLUSION

This collaborative effort provides a representative basis to estimate incidence of ARM types, to discuss differences and similarities in treatment, and health consequences throughout Europe.

Qualitative analysis of studies concerning quality of life in children and adults with anorectal malformations

INTRODUCTION

Anorectal malformations are relatively common congenital anomalies in pediatric surgery. After definitive surgery constipation, soiling, and fecal incontinence are frequently seen problems. Quality of life (QoL) can be influenced by these problems. In the last decades QoL has become an important aspect in the treatment and follow-up of patients with anorectal malformations. This has resulted in various reports concerning QoL. In order to deduce whether the drawn conclusions in the different studies are correct and can be used to adjust standard care for patients with ARM, a qualitative analysis of the studies was performed.

MATERIAL AND METHODS

A literature study was performed in PubMed, Psychinfo, Web of Science, and the Cochrane Library (240 hits). Thirty articles were used, following application of our inclusion criteria and in-depth analysis of the articles. A methodological qualitative analysis was also performed and QoL outcome assessed.

RESULTS

Six authors (20.0%) used validated QoL questionnaires. Four articles were longitudinal and had more than one measure moment. Eleven studies (36.7%) used only non-validated questionnaires, and eight studies (26.6%) used only validated questionnaires. Nineteen studies correlated fecal continence to QoL, and seven studies established no correlation. Three of these seven studies used validated QoL questionnaires. All twelve studies, which did establish a correlation, used non-validated QoL questionnaires.

CONCLUSIONS

Approximately 83% of the studies had not used validated QoL questionnaires. Further, conclusions concerning QoL were often based on functional outcomes, for example fecal incontinence. So far, longitudinal high quality research on QoL in this group has not been achieved.