Presentation of low anorectal malformations beyond the neonatal period

Clinical Differentiation between a Normal Anus, Anterior Anus, Congenital Anal Stenosis, and Perineal Fistula: Definitions and Consequences—The ARM-Net Consortium Consensus

In the past, an anteriorly located anus was often misdiagnosed and treated as an anorectal malformation (ARM) with a perineal fistula (PF). The paper aims to define the criteria for a normal anus, an anterior anus (AA) as an anatomic variant, and milder types of ARM such as congenital anal stenosis (CAS) and PF. An extensive literature search was performed by a working group of the ARM-Net Consortium concerning the subject “Normal Anus, AA, and mild ARM”. A consensus on definitions, clinical characteristics, diagnostic management, and treatment modalities was established, and a diagnostic algorithm was proposed. The algorithm enables pediatricians, midwives, gynecologists, and surgeons to make a timely correct diagnosis of any abnormally looking anus and initiate further management if needed. Thus, the routine physical inspection of a newborn should include the inspection of the anus and define its position, relation to the external sphincter, and caliber. A correct diagnosis and use of the presented terminology will avoid misclassifications and allow the initiation of correct management. This will provide a reliable comparison of different therapeutic management and outcomes of these patient cohorts in the future.

Anorectal Malformations: The Earlier the Diagnosis, the Better the Outcome

OBJECTIVE

To estimate the impact of delayed presentation of anorectal malformation (ARM) in neonates and to compare the presenting characteristics and outcomes of early versus delayed presentation.

METHODS

This is a prospective observational study of all neonates (age < 28 d) with ARM over 2 y. Delayed presentation was defined as presentation beyond 48 h of birth. Various presenting features and their early postoperative outcomes were compared.

RESULTS

Nearly half (26, 48%) of the 54 neonates with ARM had delayed presentation. Early and late presenters did not differ in terms of gender, gestational age, birth weight, place of delivery, and type of ARM (p > 0.05 for all). Delayed group had lower weight at presentation (p = 0.008), higher incidence of severe abdominal distension (p = 0.05), and sepsis (p = 0.171) and required longer time for resuscitation (p = 0.007) and more inotropes (p = 0.015), preoperatively. Early postoperative outcomes including time for stoma to function, initiate feeds and time to reach full feeds were significantly delayed in late presenters. They also had more wound infections, longer hospital stay and higher mortality.

CONCLUSIONS

Delayed diagnosis of ARM is associated with significantly higher morbidity and mortality. Adequate awareness and training of health workers for early identification of ARM by careful perineal examination of all newborns at birth is the need of the hour.

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.

Place & Person involved in delivery: Factors leading to delay in diagnosis of Anorectal Malformation in Newborns

Objective

To determine the frequency of place of delivery and person detecting the anomaly among newborn babies presenting with delayed diagnosis of anorectal malformation (ARM).

Methods

This is a Descriptive Cross-Sectional Study, conducted at Department of Paediatric Surgery, National Institute of Child Health (NICH) Karachi, from February 19, 2019 to August 18, 2019. All patients with ARM who were diagnosed beyond two hours of life (Delayed diagnosis) were included in the study. Chi square test was applied for comparison of categorical variables.

Results

Total 110 patients were enrolled in this study. Nineteen (17.3%) patients were delivered at home, while 91 (82.7%) were delivered at the hospital. The first person detecting the anomaly was grandmother (n=25) or a non-medical person in 58 patients (52.7%), 52 were diagnosed by a medical personal either primarily in 31 cases (28.2%) or secondarily by a neonatologist in 21 cases (19.1%).

Conclusion

It is concluded that Non-medical person detected ARM mainly despite the babies being delivered mostly at the hospital, indicating the need for meticulous neonatal examination.

Single stage repair of anorectal malformation with rectovestibular fistula in adult

Anorectal malformations are a wide spectrum of disorders, affecting both genders and rare adult presentation as with increased knowledge and advancements, the majority of cases are diagnosed and rectified at birth. This case is a classic example of delayed presentation caused by illiteracy and a lack of adequate health care in rural locations and highlights the uniqueness of this disease, presentation in adult age group and its management and effect on patient psychology and mental health. Because all low anorectal abnormalities can be treated in a single stage, neonatal assessment at birth and early referral to advanced health care centres are critical, with anterior or posterior sagittal anorectoplasty performed by the age of six months. Concerning the anomaly, parent education is an important aspect of patient care.

Delayed presentation of anorectal malformations in a tertiary care hospital in India

AIM

To study delayed presentation of ARMs, management and its effect on surgical and functional complications.

METHODS

It is a retrospective study from March 2015 to March 2020. All the patients satisfying the criteria of delayed ARMs, i.e., presenting 7 days after birth were included. Information regarding type of ARM, mode of presentation, time of presentation, associated anomalies, management strategy, postoperative complications and functional outcome was noted. Minimum follow-up period was 6 months.

RESULTS

Out of 102 patients with ARM, 44 patients presented late. Among the 44 patients, 9 were males and 35 were females. Associated comorbidities observed are low birth weight (n = 9) and preterm (n = 13). Associated anomalies observed were cardiac (n = 18), renal (n = 8), other gastrointestinal (n = 5) and skeletal (n = 1). (1) Male: rectourethral fistula-2 (staged repair), anal stenosis-3 (anoplasty) and anocutaneous fistula-4 (anoplasty). (2) Female: vestibular fistula: 15 (6 primary definitive surgery + 9 staged repair), ectopic anus: 3 (staged repair), anal stenosis: 2 (anoplasty), urogenital sinus: 4 (staged repair), H-type ARM: 8 (staged repair) and persistent cloaca: 3 (staged repair). Primary repair was done in 15 patients (34%), and staged repair was done in 29 patients (65.9%). Anoplasty was done in 9 patients, ASARP (modified tsuchida's procedure) in 8 patients and PSARP in 27 patients. Postoperative complications observed were constipation (n = 21, 47.7%), fecal incontinence (n = 12, 27.27%) with perianal excoriation in 2 patients, anal stenosis (n = 3, 6.8%) and rectal mucosal prolapse (n = 2, 4.5%) CONCLUSION: Delayed presentation of ARMs is not uncommon and is more common in females. Management is almost similar to those who present early. Those who present with chronic constipation and megarectum require staged repair. Complications were more frequent with delayed presentation. Hence, every newborn should have careful examination of perineum and screened for ARM to avoid possible morbidity and mortality.

15-Year-old with neglected recto-vestibular fistula in western Uganda: a case report

Background

Teenage and late presentation of anorectal malformations are not uncommon in developing world. Some of the reasons for late presentation include but not limited to illiteracy, poverty, lack of awareness, and limited trained pediatric surgeons. In rural areas, neonates with ARMs are considered cursed and are marginalized.

Case

15-Year-old African girl (a munyankole by tribe in Uganda) from western Uganda presented at 15 years of life with colostomy and uncorrected anorectal malformation. Never went to school due to social stigma.

Conclusion

Due to limited number of trained pediatric surgeons in most of African Countries, many children in addition to living with a colostomy or untreated malformation, may also be undiagnosed with chronic constipation. Improved awareness and advocacy would promote early presentation and treatment.

Comparison of longitudinal and radial characteristics of intra-anal pressures using 3D high-definition anorectal manometry between children with anoretal malformations and functional constipation

BACKGROUND

Pathophysiology of fecal incontinence (FI) in children with anorectal malformations (AM) is not well understood. Standard or high-resolution anorectal manometry (ARM) does not identify radial asymmetry or localize abnormal sphincter function. 3D high-definition anorectal manometry (HDARM) provides detailed topographic and 3D pressure gradient representation of anal canal.

AIMS

To compare intra-anal pressure profiles between children with AM and controls using HDARM and to determine the association between manometric properties and reported predictors of fecal continence (AM type, spinal anomaly, and sacral integrity).

METHODS

HDARM tracings of 30 children with AM and FI referred for ARM were compared with 30 age and sex-matched children with constipation. 2D pressure profiles were used to measure length of high-pressure zone (HPZ). Longitudinal and radial measurements of sphincter pressure at rest and squeeze were taken along each segment in 3D topographic views and compared between groups.

KEY RESULTS

3D measurements demonstrated longitudinal and radial differences between groups along all quadrants of HPZ. At rest, intra-anal pressures were lower along the four segments longitudinally across the anal canal and radially along the quadrants in AM group (P < .01). At squeeze, all quadrant pressures were lower in segments 1-4 in AM group (P < .01). Sensation was abnormal in AM group (P < .01). Intra-anal pressures longitudinally and radially were not associated with predictors of fecal continence.

CONCLUSIONS AND INFERENCES

Children with AM had abnormal sensation and lower pressures longitudinally and radially along all quadrants of anal canal. Manometric properties at rest were not associated with reported predictors of fecal continence.

Delayed diagnosis of anorectal malformations in neonates

BACKGROUND

Anorectal malformations (ARM) are common congenital abnormalities of the terminal hindgut. Ideally, ARM should be diagnosed at, or shortly following, birth by careful physical examination of the perineum. Delayed diagnosis has been implicated as a risk factor for complications, including intestinal perforation. This study aimed to determine the rate of delayed diagnosis and associated intestinal perforation in ARM.

METHODS

A retrospective review was performed for all ARM patients managed at The Royal Children's Hospital over a 16-year period (2000-2015). Data collected included ARM type, timing of diagnosis and complications. Delayed diagnosis was defined as being at more than 24 h of age.

RESULTS

A total of 243 ARM patients (male 146/243, 60%) were included. The most frequent ARM types were perineal fistula (83/243, 34%) and rectovestibular fistula (40/243, 16%). Diagnosis was delayed beyond 24 h of age in 92 of 243 (38%) patients. The ARM type most commonly delayed in diagnosis was perineal fistula (37/83, 45%). Two patients in whom diagnosis was delayed suffered an intestinal perforation.

CONCLUSION

Delayed diagnosis in ARM patients remains a common, and potentially fatal, occurrence. Improved assessment of newborns is required to ensure timely diagnosis of ARM, and avoidance of complications associated with delayed diagnosis.

Intestinal Obstruction in Early Neonatal Period: A 3-Year Review Of Admitted Cases from a Tertiary Hospital in Ethiopia

Background

Failure to pass meconium by a full-term neonate within the first 24 hours should raise a suspicion of bowel obstruction. The objective of this study was to determine pattern of presentation, diagnosis and outcome of management of intestinal obstruction in the early neonatal period in the Neonatal Care Unit of Tikur Anbessa Specialized Hospital in Addis Ababa, Ethiopia.

Methods

Retrospective chart review of admitted cases from January 2011 to December 2013 was done. Data were entered into SPSS software version 20. Descriptive analysis of data were done at first; then cross tabulation of variables with chi-square tests were done.

Results

Fifty-one (41 males and 10 females) cases of neonatal intestinal obstructions were described. ARM was the most common type of intestinal obstruction followed by intestinal atresia and Hirschsprung's disease.Delayed diagnosis of cases was observed in 72%. Associated congenital anomalies were documented in 13 % of the cases. Death occurred in 20% of the cases. One or another form of infection accounted for 90% of the deaths. Neonatal sepsis and being unfit for anesthesia were determinants of mortality with p-value <0.02 and < 0.0007 respectively.

Conclusion

Anorectal malformation is the commonest cause of early neonatal obstruction followed by small intestinal atresia and Hirschsprung's disease. Low number of associated anomalies has been reported. High rate of death due to preventable causes such as sepsis is observed. Delayed diagnosis of cases were also prevalent.

Delayed diagnosis of anorectal malformations (ARM): causes and consequences in a resource-constrained environment

PURPOSE

Delay in diagnosis or referral of patients with an anorectal malformation (ARM) is associated with significant morbidity and mortality. We describe the frequency and consequences of delay in recognition or referral of patients with ARM. Our study aims to determine whether the source healthcare facility affects the timing of diagnosis and to identify modifiable factors that may expedite diagnosis and referral.

METHODS

Retrospective study of patients referred to a pediatric surgical service with a newly diagnosed ARM between July 2002 and December 2010. Data retrieved included patient demographics, perinatal history, time of diagnosis, clinical findings, management, and morbidity and mortality. Delay was defined as diagnosis after 24 h of birth or transfer to the tertiary referral centre more than 24 h after diagnosis.

RESULTS

273 patients (186 males, 87 females) were referred during the study period. Delays were seen in 158 (57.9%) patients with morbidity in 58 (36.7%, p < 0.001) and mortality in 9 (5.7%, p = 0.008). Delay was more frequent amongst babies born in community health centres (CHCs) than in hospitals (90.5 vs. 55.1%, p = 0.002). The median age at diagnosis was 3 days (range 2 days to 5 years).

CONCLUSION

There is a need for staff education, particularly in CHCs, concerning routine neonatal examination and normal perineal anatomy. Girls, in whom a decompressive fistula is often present, are at particular risk of diagnostic delay. Delay causes increased morbidity and mortality.

Female anorectal malformation in a woman

Delayed presentation of patients with anorectal malformation is not uncommon, especially in developing countries. However, presentation beyond teenage years is not commonplace. We describe a case of a 28-year-old woman who presented for treatment due to marital issues.

Unusual presentation of a rectovestibular fistula as gastrointestinal hemorrhage in a postmenopausal woman

Background. Anorectal malformations (ARMs) are extremely rare and are usually identified neonatally. It is unusual for these cases to present in the postmenopausal period. This case report describes a postmenopausal patient with ARM and rectovaginal hemorrhage. Case. An 86-year-old, gravida 11, para 9, presented to the emergency department complaining of profuse postmenopausal vaginal bleeding. Her gynecologic history was significant only for an unclear history of an anal abnormality that was noted at birth. Speculum examination revealed profuse rectal bleeding from a rectovestibular fistula exterior to her hymenal ring. Colonoscopic examination revealed severe diverticular disease. Conclusion. This patient was born with an imperforate anus which resolved as rectovestibular fistula and ectopic anus. This case presents a rare clinical circumstance which integrates the fields of obstetrics, gynecology, gastroenterology, and embryology alike.

Review of organic causes of fecal incontinence in children: evaluation and treatment

Even though fecal incontinence (FI) in children is most commonly the result of functional constipation, there are organic conditions that can be associated with incontinence. FI has a major impact on the quality of life of those children who experience it. The general objectives of any bowel program are to achieve predictability and independence. This is achieved by manipulating colonic transit and stool consistency and by producing more controlled evacuations, usually with the use of rectal interventions. Dietary interventions and medications can be used to change stool consistency or to manipulate transit by accelerating or slowing it down. Biofeedback or other interventions that increase sphincter pressure can also be used to improve anorectal function. Enemas or suppositories can be used to empty the sigmoid colon in a more controlled manner. With the recent advent of the antegrade colonic enemas, the patient can have predictable bowel movements and become independent.

Treatment of adults with unrecognized or inadequately repaired anorectal malformations: 17 cases of rectovestibular and rectoperineal fistulas

STUDY OBJECTIVE

To analyze all cases of congenital rectovestibular and rectoperineal fistulas diagnosed and treated later in life, and to describe presenting complaints, treatment, and outcome.

DESIGN

Retrospective cohort study.

SETTING

Pediatric surgery departments of 3 major referral centers in the US and Europe.

PARTICIPANTS

Seventeen women with untreated or inadequately treated rectovestibular or rectoperineal fistulas.

INTERVENTIONS

Analyses of all eligible patients: charts were analyzed for the classification of the malformation, main complaints, continence, sexual function, indications for surgery, associated anomalies, surgical procedure, complications, and outcome.

MAIN OUTCOME MEASURES

Patients' complaints, continence, constipation, and sexual function.

RESULTS

Major complaints at time of diagnosis were fecal incontinence, and concerns for hygiene and cosmesis. All patients were repaired by a posterior sagittal approach. In all but 1 patient the complaints disappeared or improved after surgery.

CONCLUSIONS

Anorectal malformations in females are congenital malformations mostly seen and treated in early childhood. If unrepaired or inadequately repaired the patient, when reaching adulthood, can suffer from significant morbidity. Surgical treatment is similar as in childhood and has an excellent clinical outcome.

Meconium is not enough: look for the hole!

Anorectal malformations are usually diagnosed at birth, and the diagnosis is usually readily apparent in boys and girls by direct inspection of the perineal region. However, some of the less complex lesions, often referred to as 'low lesions', such as rectovestibular fistula in girls, may not be diagnosed at birth. These children are able to pass meconium, and it is only when the narrow fistula fails to pass formed stool later in infancy or childhood does the child become symptomatic. It is important to emphasise that the diagnosis of these defects should be made during neonatal predischarge examination. Such a delayed diagnosis may change their management, complicate surgical repair and may contribute to both functional and psychological problems for the patient and family.

Delayed presentation of anorectal malformation for definitive surgery

AIM

To retrospectively study the outcome of patients with anorectal malformations (ARM) presenting late for definitive procedure.

METHODS

Patients with ARM presenting beyond 5 months of age managed from January 2008 to March 2012 were studied for clinical outcome.

RESULTS

Ages at presentation varied from 5 months to 14 years, seven patients were older than 5 years of age. Of the 36 cases, 5 patients (3 boys and 2 girls) had presented with colostomy done elsewhere. Four patients had high anomalies. Of the 33 girls, 14 had rectovestibular fistula and 9 had anovestibular fistula. Bowel preparation with peglec was used in patients without colostomy. Preoperative retention enemas, laxatives and Hegar dilators were used for 3-11 days before surgery. On table irrigation was required in four. Patients without a covering colostomy were kept nil per oral for 5 days following surgery in prone/lateral position. Two patients had mild post-op wound infection, and were managed with local care.

CONCLUSION

Delayed presentation of ARM especially in girls is quite common in developing countries. With proper perioperative care, these cases may be managed successfully with a single stage procedure in most cases. The mature tissue growth with age allows proper tissue dissection and good repair of the perineal body in girls.

Delayed presentation of anorectal malformations

Aims and Objectives:

Delayed management of anorectal malformation (ARM) increases the surgical and functional complications for the patient. We defined “delayed presentation of ARM” and reviewed our patients with ARM to find out the incidence and causes of delayed presentation.

Materials and Methods:

Patients satisfying the criteria of “delayed presentation of ARM” were involved. Detailed information of each patient including the mode of presentation, associated anomalies, plan of management and follow-up was obtained from the hospital records.

Results:

Between 2003 and 2006, 43 patients satisfied our criteria of “delayed presentation of ARM”. There were 21 males and 22 females. Seventeen of these males presented with low-type ARM. Eleven of them were managed by a single-stage procedure. These “delayed presenters” had to live with constipation, inadequate weight gain and parental anxiety for a greater time. Analysis of the outcomes showed more functional complications in patients who had undergone failed perineal surgery previously. In females with low ARM, the procedure of choice was anterior sagittal anorectoplasty (ASARP). Single stage surgery provides good outcomes for most of low type of ARMs. High-type ARMs in males and females were managed by a staged procedure.

Conclusion:

“Delayed presentation of ARM” is a major group of ARM in our setup. The management and results of their treatment are not different from those of the early presenters. The most common cause of delayed ARM is wrong advice given by the health care providers followed by inadequate treatment elsewhere. Corrective surgeries taking second attempt in perineum always produces poor outcomes.

Delayed diagnosis of imperforate anus: an unacceptable morbidity

PURPOSE

Diagnosis of imperforate anus is usually made shortly after birth with physical examination. Nonetheless, a significant number of patients have presented beyond the neonatal period without recognition of anorectal malformation. We reviewed our experience of anorectal malformations, with particular emphasis on the timing of diagnosis.

METHODS

This retrospective study reviewed patients with imperforate anus between 1999 and 2009. Documentation included gender, time of diagnosis, complications, and classification. Delayed diagnosis was defined as diagnosis made >48 h of life.

RESULTS

Ninety-nine patients with imperforate anus were managed, of whom 21 presented with delayed diagnosis. The condition was classified as perineal (n = 11), recto-urethral (n = 3), vestibular fistula (n = 3) and without fistula (n = 4). Patients showed at least one of the following symptoms: abdominal distension (61.9%), bilious vomiting (38.1%), delayed passage of meconium (19.0%), and sepsis (9.5%). Delayed diagnosis was made on day 4 in median (range 3-43). This delay was associated with bowel perforation in 9.5%.

CONCLUSION

Despite routine physical examination postpartum, one in five neonates born with imperforate anus had a delayed diagnosis. This delay may lead to avoidable, serious morbidity. Therefore, we emphasise the practice of thorough perineal examination during the initial newborn examination to identify the presence of anorectal malformations.

High anorectal malformation in a five-month-old boy: a case report

Introduction

Anorectal malformation, one of the most common congenital defects, may present with a wide spectrum of defects. Almost all male patients present within first few days of life.

Case presentation

A five-month-old baby boy of Indian origin and nationality presented with anal atresia and associated rectourethral prostatic fistula. The anatomy of the malformation and our patient's good condition permitted a primary definitive repair of the anomaly. A brief review of the relevant literature is included.

Conclusion

Delayed presentation of a patient with high anorectal malformation is rare. The appropriate treatment can be rewarding.

Delayed presentation of anorectal malformations: the possible associated morbidity and mortality

AIM

Anorectal malformations (ARMs) are one of the most common congenital anomalies dealt by pediatric surgeons with reported incidence of approximately 1 in 5,000 live births. The majority of patients usually presents during the neonatal period. However a significant number of patients report later during infancy or even late childhood. Such delayed presentation may affect the surgical management and contribute to functional and psychological problems for both babies and their parents. The aim of this study is to highlight the frequency of this problem, cause of delayed presentation, and how this delayed presentation of ARM contributes to morbidity and mortality.

PATIENTS AND METHODS

During the 3-year study period, 104 cases with ARM (74 males and 30 females) were presented to pediatric surgery unit in Assiut university children's hospital. Delayed presentation means that the child came after the first 48 h or after 3 months of age in case of low ARM in females.

RESULTS

Out of 104 cases, 20 fulfil the criteria of delayed presentation (11 females and 9 males). Their age at presentation ranged from 4 days to 14 years. Fourteen classified as low ARM (6 male and 8 female), whereas six classified as high ARM (3 male and 3 female). The causes of delayed presentation were delayed detection, wrong advice to the parents, inadequate treatment offered, and social causes. The associated morbidities encountered were chronic constipation, mega rectum, and unnecessary colostomy. Two mortalities were encountered; both were males presented on days 4 and 14 after birth.

CONCLUSIONS

Delayed ARMs is not uncommon. Every neonate should be carefully examined and screened for such anomaly to avoid the possible morbidity and mortality which are directly related to this delayed presentation.

The morbidity of constipation in patients with anorectal malformations

BACKGROUND

Constipation in anorectal malformations (ARM) is extremely common, particularly in the lower types. Failure to adequately treat it can lead to significant morbidity.

METHODS

From our series of over 2000 patients with ARM, we reviewed 398 with good prognosis for bowel control and a tendency toward constipation; rectoperineal fistula (63), rectovestibular fistula (114), rectobulbar urethral fistula (104), imperforate anus with no fistula (46), rectal atresia or stenosis (9), and cloaca with a common channel below 3 cm (62). Those lost to follow-up, not yet toilet-trained (<3 years old), or with poor prognostic features were excluded. We compared morbidities in patients we operated on and managed primarily (group A, n = 268) to those managed at other institutions who suffered from constipation or incontinence and were referred to us for treatment (group B, n = 130). Those we managed primarily were subjected to an aggressive senna-based laxative program, started after their primary repair or after colostomy closure.

RESULTS

Morbidities associated with constipation were higher in the referral group and included fecal impaction (7.8% vs 38.5%), overflow pseudoincontinence (4.9% vs 33.8%), and megacolon (14.6% vs 54.6%). A loop or transverse colostomy (4.9% vs 9.2%), stoma or anorectal stricture, or a stenotic fistula (2.2% vs 28.5%) were contributing factors. Adequate laxative treatment with, in certain cases, resection of a megarectosigmoid (2.6% vs 23.1%) enabled many pseudoincontinent children to achieve bowel control (reported previously). Unneeded colorectal biopsies (1.9% vs 16.2%), Hirschsprung's-type pullthroughs (0% vs 3.1%), and, in retrospect, unneeded antegrade continent enema procedures (0% vs 3.1%) were higher in Group B. Overall, 19.8% of Group A and 66.2% of Group B experienced constipation-related morbidities.

CONCLUSION

The morbidity of constipation in ARM includes fecal impaction, megacolon, incontinence, and performance of unneeded surgeries. Inadequate treatment, the type of the original colostomy, and postoperative anal or stomal stricture as well as stenotic fistulae were key contributing factors. Children with ARM and good prognosis for bowel control are at the greatest risk for severe constipation and its consequences. With recognition and aggressive, proactive treatment, we have found that these morbidities can be reduced.

Delayed diagnosis of anorectal malformations: are current guidelines sufficient?

AIM

To determine the frequency and presenting features of infants with delayed diagnosis of anorectal malformations (ARM) referred to an Australian tertiary paediatric institution.

METHODS

Infants referred to our institution with a final diagnosis of ARM were retrospectively reviewed between 2001 and 2009. The first cohort consisted of patients that were referred between November 2001 and November 2006 with the diagnosis of an ARM that had been delayed for more than 48 h. The second cohort was those referred between December 2006 and May 2009 with whom the diagnosis of ARM had not been made within 24 h of birth.

RESULTS

Nineteen infants were referred with delayed diagnosis of an ARM over the 7.5 years of the study. Of 44 patients referred to our institution between December 2006 and May 2009, diagnosis of an ARM was delayed more than 24 h in 14 (32%). There was no difference in gender, birth weight, prematurity, type of malformation or presence of associated anomalies between those with timely and delayed diagnosis of their ARM. A significantly greater proportion of those with a delayed diagnosis presented with obstructive symptoms (86% vs. 27%, P < 0.001), including abdominal distension (57%) and delayed passage of meconium or stool (29%). Despite undergoing neonatal examination, the diagnosis of ARM was missed in 12 patients overall.

CONCLUSION

Delayed diagnosis of an ARM appears to be common, occurring in approximately 32% of patients referred to our institution over the last 2.5 years. Current guidelines appear insufficient to ensure prompt diagnosis of ARM.

Presentation of high ano-rectal malformation beyond neonatal period

Anorectal malformation is one among the common congenital malformations usually encountered. The babies usually present early after birth with complaints of missing anal opening, or abnormally placed anal opening, but some patients have presented beyond the early newborn period without recognition of their anorectal malformation. We are presenting a case of a male child with high ARM, who unusually presented first at the age of 45 days, without gross abdominal distension or septicaemia.

Delays in the diagnosis of anorectal malformations are common and significantly increase serious early complications

AIM

To clarify the extent of delayed diagnosis of anorectal malformations and the consequences of delaying this diagnosis.

METHODS

We performed a retrospective case review of all neonatal admissions with an anorectal malformation to a tertiary paediatric surgery unit. A delayed diagnosis was considered to be one made 24 h or more after birth.

RESULTS

75 patients were included in the study group: 31 (42%) had a delay in the diagnosis; 44 (58%) had no delay in the diagnosis. The time of diagnosis where a delay had occurred ranged from 2-16 (median 2) d. A delay in diagnosis could not be accounted for by differences in age, sex, birthweight, gestational age, the severity or visibility of the lesion, the need for neonatal special or intensive care, or the presence of other anomalies. There were significantly more complications (including one death) amongst the group of children who had a delay in the diagnosis of an anorectal malformation. There was no significant difference in long-term functional outcome.

CONCLUSION

Delays in the diagnosis of anorectal malformations are much more common than previously thought. A delay in diagnosis significantly increases the risk of serious early complications and death.