A unique case of complete tubular colonic duplication with normal anus accompanied by vestibular fistula in a 12 years _ old _ girl - A case report

INTRODUCTION AND IMPORTANCE

Duplication of the digestive system is one of the rare cases, which can vary in shape and size and is cystic in 80 % of cases. Most cases of duplication are often diagnosed before the age of two years. There are many ways to make the diagnosis, with computed tomography being the best, and duplication is often diagnosed during surgery.

CASE PRESENTATION

We present the case of a child suffering from complete duplication of colon with normal anus, accompanied by vestibular fistula with double urethra and vagina. The diagnosis was made at our hospital, the necessary surgery was performed, and a future plan for the child's condition was developed. CLINICAL DISCUSSION: a colonic duplication may be associated with malformations of other organs, and sometimes it may be associated with a vestibular or vaginal fistula. Therefore, we must evaluate patients for other anomalies when diagnosing a duplication. The most appropriate diagnostic method is CT, and surgery is recommended in symptomatic or asymptomatic patients.

CONCLUSION

When keeping in mind the possibility of a duplication of the digestive system, the surgeon helps to plan the surgery well, in addition to the importance of informing the parents of the possibility of eradication.

Early postoperative feeding in single-stage repair of anorectal malformation with vestibular or perineal fistula is not associated with increased wound complications

INTRODUCTION

The objective of this study is to assess the postoperative outcomes of single-stage repair of anorectal malformations with vestibular (VF) or perineal fistula (PF) and early initiation of postoperative feeding.

METHODS

A retrospective review of patients undergoing single-stage repair of isolated low anorectal malformations (VF and PF) from 2017 to 2020 was conducted. All patients underwent an anterior anoplasty with complete mobilization of the rectal fistula, or posterior sagittal anorectoplasty (PSARP), without protective colostomy. The variables examined include age, timing of postoperative feeding initiation, length of stay (LOS), and complications.

RESULTS

Nineteen patients with VF or PF underwent a single-stage repair. 12/19 (63%) patients were female. All 7 males and 9/12 females had a PF. The range of age at surgery was 2 days to 3 years with median age of 92 days [IQR 1,3: 9,193]. The median postoperative day for initiation of feeds was day 0 [IQR 1,3: 0,1] and median LOS was 1 day [IQR 1,3: 1,4.5]. 18/19 (95%) patients were evaluated in follow-up and there were no wound infections, wound dehiscences, or recurrent fistulas. Within 90 days postoperatively, no patients were seen in the emergency department for postoperative issues. Within 6 months, 2/19 (11%) patients required an unplanned return to the operating room for anal dilation.

CONCLUSION

In single-stage repair of isolated low anorectal malformations, VF and PF, early initiation of postoperative feeding is safe, results in a short length of stay, and does not lead to increased wound complications. Early enteral feeding eliminates the need for parenteral nutrition and central venous access, and their associated complications.

LEVEL OF EVIDENCE

Level IV.

Laparoscopic-assisted anorectoplasty for intermediate type rectovestibular fistula: a preliminary report

PURPOSE

Laparoscopic-assisted anorectoplasty (LAARP) is considered to benefit the male patients with anorectal malformation (ARM). This study evaluates LAARP management for intermediate type rectovestibular fistula (IRVF) in the female patient with ARM.

METHODS

Twelve patients with IRVF (aged 3-5 months) underwent LAARP from 2017 to 2019 in our institute. LAARP was performed for mobilization of the rectum, visualization and enlargement of the center of the sphincter muscle complex (SMC) from pelvic and perineal aspects, intra-fistula mucosectomy and rectal pull-through in the SMC with the fourchette and the perineal body unattached.

RESULTS

LARRP was performed in all patients without conversion to open procedure. No patient suffered from wound infection, vaginal injury, recurrent fistula and anal stenosis. The parents were satisfied with the appearance of the wound. Rectal prolapse developed in one patient and needed surgical correction. The patients were followed up for a mean of 19.7 months (ranged from 12 to 35 months).

CONCLUSION

Our preliminary experience shows that LAARP offers an alternative method of correction for the IRVF with good visualization of the SMC and may diminish the risks of wound dehiscence and vaginal injury.

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.

Middle-term bowel function and quality of life in low-type anorectal malformation

BACKGROUND

Low-type anorectal malformations (ARMs) are considered benign; however, in China, data regarding such conditions are limited. Thus, this study aimed to assess the middle-term bowel functions and quality of life (QOL) among children with low-type ARM.

METHODS

Children > 3 years of age who underwent treatment for low-type ARM (vestibular fistula [VF] and perineal fistula [PF]) during 2013 and healthy children were included. The children were interviewed during their outpatient visits. The primary outcome measures were bowel function, as assessed using the Baylor Continence Scale (BCS), and QOL, as measured using the Pediatric Quality of Life Inventory (PedsQL 4.0).

RESULTS

A total of 82 patients responded; mean patient age was 6.8 (range, 3-12) years. Mean BCS score in the control group (7.94 ± 4.74) was significantly lower than that in the VF (18.69 ± 11.11, P < 0.001) and PF (15.47 ± 6.50, P < 0.001) groups. However, there were no differences in PedsQL 4.0 scores among the groups. The patients scored the lowest for emotional function and the highest for physical function. Nearly all measurements of QOL significantly decreased with increased BCS score.

CONCLUSIONS

Children with low-type ARM can achieve good bowel control and QOL. However, although ARMs are benign, several children with this condition suffer from anal function problems that affect QOL. Redo operations, mislocated anus, and incorrect constipation treatment are the iatrogenic causes of fecal incontinence.

Single-stage repair of rectoperineal and rectovestibular fistulae can be safely delayed beyond the neonatal period

PURPOSE

We sought to examine the short-term outcomes following single-stage repair of rectoperineal and rectovestibular fistulae in infants and identify risk factors for wound complication.

METHODS

Patients with a rectoperineal or rectovestibular fistula treated with a single-stage repair beyond the neonatal period (>30days of age) at a pediatric colorectal center (2011-2016) were reviewed.

RESULTS

36 patients with a rectoperineal and 7 patients with a rectovestibular fistula were repaired using the Posterior Sagittal Anorectoplasty (PSARP) approach. Median follow-up was 31months. The median age and weight at the time of repair were 166days and 6.5kg. Four patients (11%) suffered a wound complication (3 rectoperineal, 1 rectovestibular). Two required a diverting colostomy to allow wound healing. Two patients suffered skin separation managed with local wound care. All 4 patients experienced satisfactory wound healing without anoplasty stricture. Two different patients developed a stricture of the neo-anus. Age and weight at time of repair, gender, and presence of a genitourinary anomaly were not associated with wound complications.

CONCLUSION

Delayed single-stage repair of rectoperineal and rectovestibular fistulae can be performed safely in infants beyond the newborn period. With attentive treatment, satisfactory healing can be anticipated if a wound complication is encountered.

LEVEL OF EVIDENCE

Retrospective Comparative Study, Level III.

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.

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.