Rectal duplication cyst in an adult with a history of imperforate anus: a diagnostic challenge

Rectal duplications are rare congenital anomalies that represent 1%-6% of alimentary tract duplications. We report a case of a woman in her 50s who presented to our hospital with perianal pain and urinary retention. She had a history of imperforate anus repaired after birth and dynamic graciloplasty performed during her adulthood for faecal incontinence. Abdominal CT scan showed a fluid collection extending from the electrostimulator, placed in a subcutaneous pocket in the abdomen, to the rectouterine pouch. Infection related to the electrostimulator was assumed and, after a course of antibiotics without patient improvement, the electrostimulator was removed. The symptoms and the pelvic fluid collection persisted, and diagnostic laparoscopy was performed. Diagnosis of rectal duplication cyst was made intraoperatively, and the cyst was completely resected. Patient fully recovered after surgery. This is a rare case of a rectal duplication cyst presenting during adulthood and associated with imperforate anus.

Risk factors of vesicoureteral reflux and urinary tract infections in children with imperforate anus: A population-based case-control study in Taiwan

Imperforate anus (IA) is associated with several urological anomalies, including vesicoureteral reflux (VUR), a major contributor to high morbidity in patients with anorectal malformations. This retrospective study was performed to elucidate the risk factors of vesicoureteral reflux (VUR) and UTI in children with IA.We used the National Health Insurance Research Database (NHIRD) to estimate the frequency of congenital anomalies of the kidney and urinary tract (CAKUT) in children with IA. We also investigated the frequencies of VUR, UTI, and CAKUT in children with IA along with the risk factors of VUR.We enrolled 613 children between 2000 and 2008 (367 males and 246 females; 489 low-position IA and 124 high-position IA). High-position IA was associated with a significantly increased risk of VUR compared with low-position IA (OR: 2.68, 95% CI: 1.61, 4.45). In addition, children with IA along with CAKUT, hydronephrosis, or UTI had a higher risk of VUR (OR: 8.57, 95% CI: 3.75, 19.6; OR: 7.65, 95% CI: 4.48, 13.1; and OR: 31.8, 95% CI: 11.5, 88.3, respectively). UTI, as well as chromosomal anomalies, were more frequent in children with high-position IA.Patients with a high-position IA had a greater risk of VUR, particularly those with CAKUT, hydronephrosis, or UTI. Such patients must periodically undergo urinalysis to screen for UTI and early voiding cystourethrogram to rule out VUR and prevent consequent renal damage. Chromosomal analysis is suggested to rule out Down syndrome.

Bladder Agenesis and Bilateral Ectopic Ureters in an Infant Male With Cystic Renal Dysplasia, Imperforate Anus, and Penoscrotal Transposition

Bladder agenesis is a rare congenital anomaly infrequently reported in the literature, with an incidence of 1/600,000 patients.¹ Commonly associated with other fatal malformations, the condition is often incompatible with life.² Prior reports estimate that over 90% of living children born with this malformation are female, owing to renal preservation resulting from low pressure drainage of urine into the vagina, uterus, and vestibule.^3,4 Herein we report a rare case of an infant male born with penoscrotal transposition and end stage renal disease secondary to bilateral cystic renal dysplasia found to have concurrent bladder agenesis and bilateral ureteral ectopia.

Pancreatic Malnutrition in Children

Exocrine pancreatic insufficiency in children can lead to lifelong complications related to malnutrition and poor growth. The clinical presentation can be subtle in the early stages of insufficiency as the large functional capacity of the pancreas is gradually lost. The pediatrician plays a crucial role in the early identification of these children to ensure a timely referral so that a diagnosis can be made and therapy initiated. Early nutritional therapy allows for prevention and correction of deficiencies, which leads to improved outcomes and survival. When insufficiency is suspected, the workup should start with an indirect test of exocrine pancreatic function, such as fecal elastase, to establish the diagnosis. Once a diagnosis is established, further testing to delineate the etiology should be pursued, with cystic fibrosis being high on the differential list and assessed for with a sweat test. Assessment of anthropometry at every visit is key, as is monitoring of laboratory parameters and physical examination findings that are suggestive of malabsorption and malnutrition. The mainstay of management is administration of exogenous pancreatic enzymes to facilitate digestion and absorption. [Pediatr Ann. 2019;48(11):e441-e447.].

A rare cause of pancreatic insufficiency; Johanson Blizzard Syndrome

Johanson-Blizzard Syndrome (JBS) was first described by Johanson and Blizzard. It exhibits autosomal recessive inheritance and is characterized by mutation in the UBR1 gene on the long arm of Chromosome 15. The phenotypic features as well as diarrhoea that occurs due to the exocrine pancreatic insufficiency constitute the main clinical symptoms. This article discusses Johanson-Blizzard Syndrome due to the case followed-up by us with the symptoms of deafness and diarrhoea as well as typical facial appearance.

Diagnostic Accuracy of Sonography for Detection of a Fistula on the Birth Day in Neonates With an Imperforate Anus: Comparison of Diagnostic Performance Between Suprapubic and Perineal Approaches

OBJECTIVES

To evaluate the diagnostic accuracy of sonography for detection of an internal fistula on the birth day in neonates with an imperforate anus and to compare the diagnostic performance between the suprapubic and perineal approaches.

METHODS

We included 46 neonates with an imperforate anus (29 low type and 17 intermediate/high type) who underwent sonography by both the suprapubic and perineal approaches on the birth day. Thirty-nine neonates had internal fistulas, and 12 did not, as surgically proven. Two blinded radiologists evaluated the suprapubic and perineal sonograms for the presence of the internal fistula in consensus. A final diagnosis of the internal fistula was determined on the basis of the findings of both approaches. A receiver operating characteristic analysis was used to compare the diagnostic performance for detection of an internal fistula between the suprapubic and perineal approaches.

RESULTS

The sensitivity, specificity, and accuracy of the final diagnosis based on the findings of suprapubic, perineal, and both approaches were 52.9%, 79.4%, and 79.4%; 75.5%, 75.5%, and 75.5%; and 58.7%, 78.3%, and 78.3%, respectively. The diagnostic performance of the perineal approach was significantly better than that of the suprapubic approach (P < .0001).

CONCLUSIONS

The diagnostic accuracy of sonography for detection of an internal fistula on the birth day exceeded 75% in neonates with an imperforate anus, and sonography on the birth day is feasible. The perineal approach had superior diagnostic performance over the suprapubic approach. Thus, when evaluating an internal fistula by sonography, we recommend using the perineal approach in addition to the suprapubic approach.

Dental Treatment Considerations for Children with Complex Medical Histories: A Case of Townes-Brock Syndrome

It is common for oral health and dental care to be considered a lesser priority for children with complex medical histories than other aspects of their health care. Often, these patients are at a high risk for caries and infection due to poor oral health practices at home, special or restricted diets, and no early establishment of a dental home for routine dental care. Unfortunately, many of these patients present to their first dental visits with caries and require aggressive treatment, such as extractions instead of pulp therapy, or crowns instead of fillings, due to their high caries risk and the difficulty in safely managing them medically during treatment. A unique example of this occurred at the Children's Hospital of Michigan, where a patient with Townes-Brock syndrome (TBS) presented to the dental clinic with advanced caries. TBS is a rare autosomal dominant disorder characterized by major findings such as anomalies of the external ear, imperforate anus, renal malformations, and malformations of the hand. Like many medically complex cases, dental anomalies are not a direct consequence of TBS; however, due to the necessity of high calorie and high sugar feeding supplementation, many of these patients are at high risk for advanced dental caries. Due to this high caries risk, a more aggressive treatment plan is necessary to minimize the risk of recurrent decay and infection. It is critical to stress that even if the disease, syndrome, etc., of a patient does not have inherent dental consequences, it is imperative for regular dental care to be part of the comprehensive treatment plan for these patients. This includes the establishment of a dental home at a young age and proper oral health education of the patient's caregivers and their physicians. In the case of the patient with TBS, recommendations for daily brushing, especially after high sugar feedings was stressed, as well as the reduction of any other sweets within the diet.

Enterolith causing bladder outlet obstruction in patient with imperforate anus. A rare case presentation

Imperforate anus is a rare anomaly associated with defects commonly referred to as vertebral defects, anal atresia, cardiac defects, tracheo-oesophageal fistula, renal anomalies and limb abnormalities (VACTERL). With modern surgical procedures the overall outcome is excellent. Permanent colostomy which is required in some cases of this disease can result in some rare complications such as enteroliths formation, as illustrated in the case we are presenting here related to a 28-year-old male who reported at urology emergency with features of urinary and acute large bowel obstruction. On investigation he was found to have two enteroliths in his distal loop of sigmoid colostomy. The more distal of the two enteroliths caused urinary retention and hence acute renal failure, and the proximal one caused large bowel obstruction by compressing the proximal loop of colostomy. This case demonstrates that the blind distal sigmoid colostomy loop can grow enteroliths secondary to stasis of its own contents over a long period.

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.

Adolescents with anorectal malformation: physical outcome, sexual health and quality of life

BACKGROUND

The necessity of referring adolescents with anorectal malformation (ARM) from pediatric units to adult care is unclear. The issue requires knowledge about the health of the adolescent.

OBJECTIVE

To examine the physical outcome, sexual health and quality of life (QoL) in adolescents with ARM.

METHODS

At medical counseling, 24 adolescents with ARM, 15-21 years of age, answered questionnaires about physical outcome according to the Krickenbeck follow-up and QoL according to SF 36 and gastrointestinal quality of life (Giqli). Matched control groups were used; 15 adolescents participated in deep interviews about sexual health and body imaging.

RESULTS

Fecal soiling, constipation and gas incontinence were much higher for ARM patients compared with controls (p<0.05). QoL regarding large bowel function was lower for both genders compared with controls (p<0.05). Females scored lower in physically related QoL (p<0.05). Social and sexual adaption to the symptoms was obvious in the deep interviews.

CONCLUSION

Adolescents with ARM have considerable intestinal symptoms, which influence QoL and require adaption in intimate situations. A referral to adult care seems to be important, and continuous cooperation between the pediatric surgeon and adult care is suggested.

[Clinical application of magnetic resonance imaging in congenital anorectal malformation]

OBJECTIVE

To investigate the clinical value of MRI examination in congenital anorectal malformation (CARM).

METHOD

Forty-four cases with operatively proved anorectal malformation from May 2008 to May 2012 in the authors' hospital were reviewed. Of the 44 cases, 25 were males and 19 females, their age ranged from 1 day to 2 years. MRI was performed in all patients.

RESULT

Of all 44 cases, 15 cases had high imperforate anus (34%), rectum blind end were above PC line, the distance of rectum blind end and anus nest was (29.12 ± 2.35) mm; 8 cases had median imperforate anus (18%), rectum blind ends were near PC line, the distance of rectum blind end and anus nest was (18.98 ± 2.21) mm; 21 cases had low imperforate anus (48%), rectum blind ends were below PC line, the distance of rectum blind end and anus nest was (7.54 ± 1.08) mm. Twenty-five cases with fistula in 44 cases were confirmed by rectal angiography and surgery, accounting for 57%. In 13 cases with fistula, the lesion could be clearly demonstrated on MRI, in the remaining 12 cases with fistula, the lesion could not be visualized clearly or no image development occurred on MRI. Of all 44 cases, 1 case had tethered cord with filum terminale lipoma, 1 case had tethered cord, 2 cases had syringomyelia, 1 case had right kidney agenesis, 1 case had hydrocele. In 44 cases of multi-planar MRI imaging could clearly show the perianal muscles developmental situation, 36 cases had perianal muscles dysplasia, amd showed levator ani muscle, puborectalis and anal sphincter asymmetry, muscle belly slim.

CONCLUSION

MRI examination has a high clinical value in CARM diagnosis, can help accurately judge the anal atresia type, display the presence and running of most of the fistula, and diagnose perianal muscle development and other systems malformations, finally provide a reliable diagnostic basis for surgical program and prognostic assessment.

Laparoscopy-assisted surgery for male imperforate anus with rectourethral fistula

Laparoscopically assisted anorectal pull-through (LAARP), first described by Georgeson, is now considered to be the radical surgical treatment of choice for rectourethral fistula (RUF) in boys with high/intermediate-type imperforate anus. Accurate positioning of the pull-through canal, with pelvic floor muscles surrounding it symmetrically, is well recognized as the most important prognostic factor irrespective of the procedure performed. Surgical intervention should be LAARP with intraoperative measurement of the RUF, with follow-up focused on bowel habit. Complications such as diverticulum formation, have been reported with increasing frequency after LAARP and are most likely related to incomplete excision of the RUF, especially in bulbar cases. Thus, complete excision, while technically challenging, is crucial. Based on the results of a multicenter study comparing LAARP with other surgery, the most reliable investigation for detecting the presence of a diverticulum is MRI. At Juntendo University Hospital in Tokyo, Japan, blunt dissection with mosquito forceps to identify the potential pull-through canal, measuring the length of the RUF directly, and closer placement of trocars (in bulbar fistula cases) are homegrown refinements that we feel improve outcome and we present a review of our approach to the surgical management of ARM.

MRI findings in patients with defecatory dysfunction after surgical correction of anorectal malformation

BACKGROUND

Postoperative anorectal malformation patients frequently have defecatory dysfunction. MRI may be useful in the management of these patients.

OBJECTIVE

To analyze static and dynamic MRI findings in patients with defecatory dysfunction after correction of anorectal malformation (ARM), and compare differences between patients with constipation and fecal incontinence.

MATERIALS AND METHODS

Pelvic MRI studies of 20 constipated and 32 incontinent postoperative ARM patients were analyzed retrospectively to determine the location and morphology of the neorectum, presence of peritoneal fat herniation, presence of scarring, development of the striated muscle complex (SMC) and any other abnormalities. The two groups were then compared using χ(2)-test. Eighteen patients also underwent MRI defecography to evaluate pelvic floor function and abnormalities are reported.

RESULTS

The children with incontinence were more likely to have abnormal location of the neorectum (P = 0.031), increased anorectal angle (ARA) (P = 0.031) and peritoneal fat herniation (P = 0.032), and less likely to have dilation of the neorectum (P = 0.027), than the children with constipation. There were no significant differences between the two groups in incidence of focal stenosis of the neorectum (P = 0.797), presence of extensive scarring (P = 0.591) and developmental agenesis of the SMC (P > 0.05). MRI defecography showed 6 anterior rectoceles, 6 cystoceles and 18 pelvic floor descents.

CONCLUSIONS

MRI is a helpful imaging modality in postoperative ARM patients with defecatory dysfunction, and it shows distinct differences between the children with constipation and incontinence and provides individualized information to guide further treatment.

Neonatal colon perforation due to anorectal malformations: Can it be avoided?

Anorectal malformations (ARM) are common anomalies in neonates. Diagnostic and therapeutic delays in the management of ARM may lead to colonic perforation, and even death. Physical examination of the perineum is often sufficient to diagnose ARM in neonates. Notwithstanding, delayed diagnosis of ARM has become increasingly familiar to surgeons, as evidenced by the number of recent publications on this topic in the literature. In this commentary, we discuss spontaneous colonic perforation due to delayed diagnosis of ARM in neonates, and highlight the importance of early diagnosis in assuring good outcomes with surgical management. At this point, a thorough examination of the perineum during the initial newborn assessment is mandatory, particularly in those patients presenting with abdominal signs or symptoms.

Longitudinal study of bowel function in children with anorectal malformations

PURPOSE

Longitudinal follow-up of changes in bowel function in children with anorectal malformations (ARMs) with or without spinal cord pathology and neurogenic bladder dysfunction (NBD) as they grow. Another purpose was to identify predictors influencing bowel functional outcome.

MATERIAL AND METHODS

The study included 41 patients with ARM, excluding perineal fistula (21 boys and 20 girls). Bowel function was evaluated at ages 5, 10 and 15 years using a structured questionnaire and a three-week registration of number and time of bowel movements, episodes of fecal leakage and soiling. Additional bowel treatment with enemas and stool softeners and use of diapers were recorded. A group of 52 healthy boys and girls was used as control.

RESULTS

A successive improvement in functional outcome with age in children with ARM and normal spinal cord was seen with respect to continence, soiling and constipation. Continence was achieved earlier in girls than in boys (at 10 years: girls 80%, boys 36%). Soiling and constipation decreased with age both in grade and frequency (at 10 years low grade soiling: girls 53%, boys 64%). Boys with spinal cord malformation with NBD in combination with prostatic/bladder neck fistula (PRF/BNF) and sacral agenesis had the worst functional outcome with minimal possibility of improvement over time. Functional outcome in girls with NBD and tethered cord did not differ significantly from those without NBD and with a normal spinal cord. Psychosocial co-morbidity, neuropsychiatric disorders, developmental delay and megarectosigmoid were also risk factors impeding the functional outcome.

CONCLUSION

In the present study there was a successive improvement in bowel function during childhood and adolescence in ARM children, but they did not achieve the level of healthy children. NBD, spinal cord malformation, sacral malformation and PRF all were negative predictive factors for bowel score at 5 years.

Anorectal malformation and associated end-stage renal disease: management from newborn to adult life

BACKGROUND/OBJECTIVE

Renal failure remains one of the most significant causes of morbidity in patients with anorectal malformations (ARM). In the modern era, an increasing number of children born with ARM and genito-urinary (GU) anomalies reach adulthood and require continued multidisciplinary care for the rest of their life. The aim of this study is to present our institutional experience in the management of pediatric chronic renal failure related to severe GU anomalies and anorectal malformations.

METHODS AND RESULTS

Three hundred twenty-one patients with ARM have been followed at our institution since 1987. Six patients developed end-stage renal disease (ESRD) and received a kidney transplant at different ages. One patient is currently followed for mild, progressive chronic renal failure. These seven cases are reported along with a broad discussion concerning etiology of renal failure, neonatal surgical management, pediatric dialysis, urologic issues, and kidney transplantation.

CONCLUSION

Complex GU anomalies associated with ARM require a long-term approach by specialized pediatric and adult clinicians to optimize the care of this selected population of patients.

Pyosalpinx and hydrosalpinx in virginal adolescents: report of two cases

Pyosalpinx and hydrosalpinx are conditions mainly seen in adult women, but also among sexually active adolescents and can bring added hazard to fertility. However these conditions are very rare in childhood, as well as in adolescent girls who are not sexually active. We are presenting two rare cases of young girls in early puberty with hydrosalpinx and pyosalpinx. Both girls had a history of abdomino-pelvic surgery in childhood for congenital bowel anomalies and fecal incontinence. Such cases are good reminders that girls with known abdomino-pelvic anomalies and surgical procedures in childhood need long term follow-up, in particular when entering puberty and maturation. The two cases show how fallopian tubes can be indirectly affected and present in adolescence with serious problems needing surgical procedures and potentially threatening future reproductive system performances.

Laparoscopic-assisted PSARP - the advantages of combining both techniques for the treatment of anorectal malformations with recto-bladderneck or high prostatic fistulas

AIM

The aim of this study was to present an alternative way to use both the posterior sagittal approach combined with laparoscopy for the repair of select cases of anorectal malformation (ARM).

METHODS

The laparoscopic approach was used for rectal dissection, ligation of the fistula, and division of vessels to pull the rectum down in cases of ARM with recto-bladderneck or high prostatic fistula. The posterior sagittal incision we believe made the perineal portion safer, allowing for rectal tapering when necessary, and for accurate placement of the rectum, anchored in the center of the sphincter.

RESULTS

There were 15 children (recto-bladderneck fistula, n=13 and recto-prostatic fistula, n =2) in this series. There were no urethral injuries, posterior urethral diverticula, or rectal strictures. A laparotomy was needed in two children in order to mobilize a very high rectum. Follow-up ranged from 3 months to 10 years. Clinical results were consistent with our published series for male patients with these types of defects: 5 are fecally incontinent (3 are clean with a bowel management program), 1 is fecally continent, and 9 are too young to assess. Four children suffered rectal mucosal prolapse.

CONCLUSION

The combination of laparoscopy and PSARP represents a useful technical alternative that allows for a safe reconstruction in cases of ARM with recto-bladderneck and in selected high prostatic fistulas.

Anomalies associated with anorectal malformations

BACKGROUND

The purpose of the paper is to review the incidence of associated congenital anomalies that are encountered in patients presenting anorectal malformations and compare these results with those previously published.

MATERIAL AND METHODS

A number of 50 cases with ARM from our institution were reviewed (from 2005 to 2012) and information was collected on patient demographics, type of ARM and associated congenital anomalies, the latter being then categorized according to organ systems.

RESULTS

Out of 50 newborns, 28 were males and 22 females (1.27:1). 34 (68%) had at least one associated abnormality. The majority of patients (40%) had imperforated anus without fistula. The most frequent seen anomalies were gastrointestinal (36%), urogenital (24%) and cardiovascular (16%).

CONCLUSIONS

More than half of the children included in our series have other associated abnormalities. We found gastrointestinal anomalies to be the most common associated congenital defects in our patients. A higher incidence of this type of anomalies was encountered in newborns with persistent cloacal anomaly. The rectovestibular fistula group was most likely to present cardiac abnormalities. The incidence of genitourinary anomalies in the perineal fistula group is higher than the one described in other studies.

[Anesthetic management of a neonate with esophageal atresia, tracheoesophageal fistula and imperforate anus]

Esophageal atresia is a rare condition (1:2,500-4,500), incompatible with life, and a surgical emergency in the neonatal period. It is associated with prematurity in 30% of cases, and to congenital abnormalities in 50% of cases, especially cardiac anomalies. Major congenital heart diseases and low weight are independent predictors of mortality and critical perioperative events. The aim of this article is to describe the most significant anaesthetic challenges presented in a case of a term neonate undergoing emergency surgery after being diagnosed with esophageal atresia, tracheoesophageal fistula type iiib/C, and imperforate anus. The major priorities during the anaesthetic management consist of establishing a safe airway and effective pulmonary ventilation that minimises air leakage to the upper digestive tract.

Alveolar capillary dysplasia with anorectal anomaly

Alveolar capillary dysplasia (ACD) is an uncommon cause of irreversible persistent pulmonary hypertension in full-term newborn. In ACD there is a failure of formation of air - blood barrier in addition to misalignment of pulmonary veins. The etiology of the disease is still not understood. We present a case report of a full-term newborn with ACD associated with anorectal anomaly.

VACTERL/VATER Association

VACTERL/VATER association is typically defined by the presence of at least three of the following congenital malformations: vertebral defects, anal atresia, cardiac defects, tracheo-esophageal fistula, renal anomalies, and limb abnormalities. In addition to these core component features, patients may also have other congenital anomalies. Although diagnostic criteria vary, the incidence is estimated at approximately 1 in 10,000 to 1 in 40,000 live-born infants. The condition is ascertained clinically by the presence of the above-mentioned malformations; importantly, there should be no clinical or laboratory-based evidence for the presence of one of the many similar conditions, as the differential diagnosis is relatively large. This differential diagnosis includes (but is not limited to) Baller-Gerold syndrome, CHARGE syndrome, Currarino syndrome, deletion 22q11.2 syndrome, Fanconi anemia, Feingold syndrome, Fryns syndrome, MURCS association, oculo-auriculo-vertebral syndrome, Opitz G/BBB syndrome, Pallister-Hall syndrome, Townes-Brocks syndrome, and VACTERL with hydrocephalus. Though there are hints regarding causation, the aetiology has been identified only in a small fraction of patients to date, likely due to factors such as a high degree of clinical and causal heterogeneity, the largely sporadic nature of the disorder, and the presence of many similar conditions. New genetic research methods offer promise that the causes of VACTERL association will be better defined in the relatively near future. Antenatal diagnosis can be challenging, as certain component features can be difficult to ascertain prior to birth. The management of patients with VACTERL/VATER association typically centers around surgical correction of the specific congenital anomalies (typically anal atresia, certain types of cardiac malformations, and/or tracheo-esophageal fistula) in the immediate postnatal period, followed by long-term medical management of sequelae of the congenital malformations. If optimal surgical correction is achievable, the prognosis can be relatively positive, though some patients will continue to be affected by their congenital malformations throughout life. Importantly, patients with VACTERL association do not tend to have neurocognitive impairment.

Oesophageal atresia without tracheo-oesophageal fistula and an anorectal malformation: advantages of a primary laparoscopically assisted anorectal pull-through

We report on a primary laparoscopically assisted anorectal pull-through (LAARP) performed in a neonate with pure oesophageal atresia and imperforate anus with recto-bulbo-urethral fistula, representing a unique case for the LAARP approach owing to the undistended nature of the bowel and sterile meconium. Further evaluation of the applicability of LAARP in the management of infants with anorectal malformations is needed, but in this case it held major advantages for the patient. A laparoscopically assisted gastrostomy was facilitated during the same procedure, while avoidance of a colostomy and its associated complications also facilitated preservation of the left colon for subsequent use in oesophageal replacement. Long-term outcome remains to be assessed.

The right sided syndrome, congenital absence of kidney and testis

Unilateral renal agenesis (URA) is a developmental defect associated with ano-malies of the genitourinary system. The associations vary from absence of testis alone to high anorectal anomalies in other patients. We present two interesting patients with URA, encountered recently. Our first case was diagnosed with URA at the age of 11 years, which was detected on sonography, when he presented with pain abdomen. The presence of an epididymal cyst masked the absence of ipsilateral testes leading to delay in the diagnosis. Our second case was diagnosed with URA during the neonatal period when he presented with anorectal agenesis. He underwent abdomino-anal pull-through operation and later clinical course was complicated by recurrent cystitis, secondary vesicoureteral reflux and hydroureteronephrosis of solitary kidney, progressing to chronic kidney disease.

Neuro-orthopedic manifestations of the omphalocele exstrophy imperforate anus spinal defects complex

PURPOSE

The omphalocele-exstrophy-imperforate anus-spinal defects complex is a severe multisystem congenital defect. To comprehensively care for these patients one must appreciate the neurological and orthopedic impact on the overall health of the child.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of 73 children with omphalocele-exstrophy-imperforate anus-spinal defects who were treated at our institution, identifying neurological and orthopedic anomalies, ambulatory ability and voiding status.

RESULTS

No neurological data were available on 5 patients. Of the remaining 68 patients 9 had no spinal anomaly, 57 had spina bifida, 1 had hemivertebrae and 1 had coccygeal hypoplasia. We further classified the 47 spina bifida cases as spina bifida occulta in 6, meningocele/lipomeningocele in 12, myelomeningocele/lipomyelomeningocele in 24 and sacral agenesis in 6. Of the patients with spina bifida 35 had cord tethering. Commonly identified orthopedic anomalies were vertebral malformation in 59 patients, scoliosis in 25, clubfoot in 14 and limb length discrepancy in 8. Ambulatory status in 62 patients of walking age revealed that 37 ambulated fully, 15 ambulated with devices, 2 ambulated minimally with devices and 8 were wheelchair bound. Continence data were available on 61 closed cases. Of these patients 26 were incontinent, including 3 with conduit diversion, 1 with ureterostomy and 1 with vesicostomy. A total of 35 patients were socially continent, of whom 30 catheterized via a continent abdominal stoma and 5 voided/catheterized via the urethra.

CONCLUSIONS

Early evaluation for neurosurgical and orthopedic anomalies is vital in these children. Despite the high incidence of spinal pathology most patients ambulate without assistance. Few children with omphalocele-exstrophy-imperforate anus-spinal defects achieve continence via the urethra. Vigilant followup is necessary to identify potentially correctable conditions.

Fetal bowel calcifications: a sign of anal atresia with rectourethral fistula

Fetal bowel calcifications were observed at 24 weeks of gestation in a male fetus, suggesting an anorectal malformation (ARM) with rectourethral fistula. At birth, the newborn presented with complex ARM including anal atresia, rectourethral fistula, and esophageal atresia. The prenatal sonographic visualization of calcifications within distended bowel should raise the suspicion of ARM including anal atresia and rectourethral fistula, the presence of such calcification depending on the timing of onset of fistula formation.

A Turner syndrome case associated with anal atresia, interrupted aortic arch and multicystic dysplastic kidney

Although renal and cardiac malformations are commonly seen in Turner syndrome (TS), anorectal malformations, multicystic dysplastic kidney and interrupted aortic arch are quite rare in TS. A newborn with TS with three quite rare congenital malformations (imperforate anus/anal atresia associated with rectovestibular fistula, interrupted aortic arch, and multicystic dysplastic kidney) is presented.

Medical and surgical management of fecal incontinence after repair of high imperforate anus anomalies

OBJECTIVE

To report the medical and surgical management of fecal incontinence in children after repair of high imperforate anus.

METHODS

Thirty-seven children with fecal incontinence post repair of high imperforate anus were recruited between January 2000 and July 2007 at Aseer General Hospital, Abha, and Alhada Military Hospital, Taif, Kingdom of Saudi Arabia. The decision for surgery (dynamic graciloplasty) was based on the degree of incontinence and failure to respond to medical treatment. Five children were operated from the start according to the input of history, examination, and investigations (incontinence score of 15-20). The remaining 32 patients were treated medically. Those cases that failed to respond to medical treatment had alternatively biofeedback therapy. Cases that failed to respond to biofeedback therapy underwent surgery.

RESULTS

Response to medical treatment is favorable (71%). Biofeedback showed discouraging results (22%). Dynamic graciloplasty showed excellent outcome (100% improvement in continence on long term follow up).

CONCLUSION

Based on history, examination, and investigations, recruited cases were primarily treated medically; those who had failed the medical treatment approach had dynamic graciloplasty, which demonstrated excellent results during the 1-7 years follow-up period.

The challenge of obtaining continence in a child with a neurogenic bowel disorder

Fecal incontinence in pediatrics can occur from an array of conditions. A challenging group of pediatric patients are those with a neurogenic bowel disorder who can face a lifelong struggle with attaining and maintaining continence. It is difficult to develop a "cookbook approach" to care, particularly because these children's unique physical needs change as they develop. In addition to addressing physical needs, children's emotional and developmental needs must also be incorporated into the plan of care. This article provides an overview of the common congenital conditions in children with a neurogenic bowel, reviews assessment, and addresses treatment options that should be considered when developing a bowel management program.

Single stage repair of anovestibular fistula in neonate

Anorectal malformations are one of the most common congenital defects. This study is conducted to evaluate the result of single stage anterior sagittal anorectovaginoplasty (ASARVP) in cases of vestibular anus (AVF) in neonatal age group without thorough gut preparation. All the patients of AVF admitted during 2003-2006 were included in this study. Single stage ASARVP was done in these patients without preparing the bowel in the lithotomy position, the fistula was freed and sufficient length of anorectum was dissected and vagina was separated. Midline incision at the proposed anal site was made, then a plane was dissected between the muscle complex going anteriorly. The mobilized anorectum was pulled to the proposed anal site and proper anoplasty was done. The results were evaluated for duration of surgery, need of bowel preparation, commencement of feed and hospital stay and follow-up (assessment of continence and anal dilatation). A total of 27 patients were included in our study. All patients were less than 1-month-old. Operative time ranges from 50 to 70 min. Bowel preparation was not needed. Per oral feed was started after 48 h in all patients and average duration of hospital stay was 3- 4 days. Postoperative regular anal dilatation was commenced after 1 week of operation. Continence results according to Kelly's method were good in 70%, fair in 21% and poor 9%. Single-stage anorectovaginoplasty in neonates has a good result in cases of AVF and avoids the need of bowel preparation.

Tethered spinal cord and VACTERL association

OBJECT

Vertebral defects, anal atresia, cardiovascular anomalies, tracheoesophageal fistulas (TEFs), renal anomalies, and limb defects (most often of the radius) are commonly associated and known collectively by the acronym VACTERL. The authors studied these nonrandomly associated birth defects to determine if a further relationship exists between VACTERL association and the presence of a tethered spinal cord (TSC).

METHODS

From 2001 to 2004, 12 patients with VACTERL association who were treated operatively by a single pediatric surgeon underwent magnetic resonance (MR) imaging to evaluate the intraspinal abnormalities that may cause tethering. Three patients were excluded from the study due to complications after surgery for TEF. Coincidentally, these three patients did not have imperforate ani. In the remaining nine patients, seven had associated urogenital anomalies, and six of these also had high-type imperforate ani. Five of the six patients and the one patient with low-type imperforate anus and a urogenital anomaly were found to have TSCs. In the remaining two patients without urogenital anomalies there was a high-type imperforate anus without a TSC in one patient and a low-type imperforate anus with a TSC in the other. All seven patients with TSCs underwent successful untethering. The lesions contributing to TSC included terminal filum lipomas (TFLs) in five patients, an intramedullary ependymal cyst in one patient, and a lipo-meningomyelocele in another patient.

CONCLUSIONS

The authors found that in patients with VACTERL association there was a high incidence of TSC (seven of nine patients) if an imperforate anus was present as one of the anomalies. In patients with VACTERL association and urogenital anomalies, the incidence of TSC was even higher (86%). Five of the seven cases of TSC in the present study were caused by a TFL, a lesion that can be easily and safely managed surgically. The authors conclude that MR imaging is essential for ruling out the possibility of a TSC in patients with VACTERL association combined with urogenital anomalies or an imperforate anus.

Townes-Brocks syndrome with hypothyroidism

Townes-Brocks syndrome (TBS) is an autosomal dominant disorder with multiple malformations and variable expression. Major findings include external ear anomalies, hearing loss, limb deformity, imperforate anus, and renal malformations. Hypothyroidism is not a recognized feature of TBS. We are reporting a case of TBS with hypothyroidism, a rare association.

Parental experiences: care of children with high and intermediate imperforate anus

In this study parental experiences of care of children with high and intermediate imperforate anus were evaluated. A group of 45 parents of children with high and intermediate imperforate anus and two control groups participated. Data collection with individual questionnaires concerning the child's hospital care, information to the parent and the child, and involvement in the care of the child were performed. Parents of children with imperforate anus reported being less satisfied with the care of their child, and they were less content with information about their child's treatment compared with the control groups. The parents had been extremely involved in the follow-up treatment. Constipation and fecal incontinence are common and involve suffering for the children and their parents. Parents have to be motivated and supportive and have a great deal of patience to be able to put up with caring for these children, and it seems as if health care professionals have underestimated their problems.

Occult neurovesical dysfunction with anorectal malformations

OBJECTIVE

To evaluate for the occurrence of occult NVD in children with anorectal malformations (ARM) using urodynamic evaluation.

METHODS

This prospective study was carried out on children with ARM prior to and following definitive procedure. Urodynamic studies were performed on the Phoenix Griffon machine (Albyn Medical) using Phoenix plus software.

RESULT

Nineteen children in the age range of 3 months to 156 months (mean = 19.2) were included in this study. Among these 19 children 13 underwent re-evaluation after definitive surgery for ARM. There were 11(57.9%) males and 8(42.1%) females. Of the 19 children 14 (73.7%) were cases of high anorectal malformation (HARM) and 5 (26.3%) were cases of low anorectal malformation (LARM). Baseline evaluation done in 19 children revealed seven urodynamic patterns: Normal capacity, compliant without uninhibited contractions (UIC) (21.1%); Normal capacity, compliant with UIC (5.3%); Normal capacity, poorly compliant without UIC (5.3%); Normal capacity, poorly compliant with UIC (10.5%); small capacity, compliant with UIC (5.3%); Small capacity, poorly compliant with UIC (26.3%) and large capacity, complaint with UIC (26.3%). Thirteen patients were evaluated post operatively also and in only 23% (3 of 13) no change in urodynamic pattern were observed. In the remaining 76.9% (10 of 13) some changes in urodynamics pattern were observed. The deleterious changes observed were appearance of UIC in 30.8% (4 of 13), decrease in the bladder capacity in 23% (3 of 13) and decrease in bladder compliance in 15.4% (2 of 13).

CONCLUSION

Only 9 of of the 19 patients had normal urodynamics pre-operatively and post-operatively 3 more patients worsened. Incidence of occult NVD is high in patients with ARM even in the absence of clinical and radiological evidence of vertebral or lower urinary tract abnormalities. Though there seems to be a high incidence of changes in the neurovesical functions of these patients following definitive corrective surgery for ARM only time will show whether this has any deleterious effect on the upper tracts.

Handless, footless fetus

We report a fetus with symmetrical terminal transverse limb deficiency. Two earlier reports described patients with similar defects. These patients resemble the animal models that result from the removal of apical ectodermal ridge.

Echogenic foci in the dilated fetal colon may be associated with the presence of a rectourinary fistula

Intraintestinal meconium calcification in the fetus and newborn is a rare finding, occurring in patients with intestinal obstruction. The intraluminal location of the enterolithiasis enables differentiation from calcifications that are secondary to bowel perforation and meconium peritonitis. We report on a term male neonate with VACTERL (vertebral defects, imperforate anus, cardiac anomalies, tracheoesophageal fistula, renal anomalies, limb anomalies) association and rectourethral fistula, in whom enterolithiasis was documented by prenatal ultrasound imaging at 21 weeks' gestation. A review of the literature and a summary of all previously described cases of neonates with intraluminal meconium calcifications are provided. Prenatal ultrasonographic detection of enterolithiasis in fetuses with anal atresia may indicate the presence of an enterourinary fistula.

PELVIS Syndrome

BACKGROUND

Large perineal hemangiomas can be associated with congenital anomalies, including anorectal, urinary tract, spine, and external genitalia malformations.

OBSERVATIONS

We describe 2 infants with large sacral and perineal hemangiomas, with severe malformation of the external genitalia with ambiguous genitalia in one case and urinary tract malformations and imperforate anus in the other case. These cases are discussed, along with 9 previously reported cases with similar findings.

CONCLUSIONS

Large perineal hemangiomas may constitute a distinctive group of associated anorectal, neurologic, renal or urinary tract, and genital defects. We propose the acronym PELVIS syndrome to emphasize the characteristic findings of this syndrome: perineal hemangioma, external genitalia malformations, lipomyelomeningocele, vesicorenal abnormalities, imperforate anus, and skin tag.

Is an Anal Plug Useful in the Treatment of Fecal Incontinence in Children With Spina Bifida or Anal Atresia?

PURPOSE

We evaluated the efficacy and tolerance of the Conveen anal plug in children with spina bifida or anal atresia with persistent fecal incontinence necessitating diapers despite bowel management.

MATERIALS AND METHODS

Seven 4 to 12-year-old patients with high congenital imperforate anus and 9 who were 6 to 13 years old with spina bifida, no mental retardation and no involuntary urine loss on clean intermittent catheterization were included in the study. During a prospective, 6-week crossover descriptive study after a test period to find the most comfortable plug with a diameter of 37 or 45 mm patients and parents completed a diary with the number of soiling episodes, stool frequency, stool consistency and the number of diapers used during 3 weeks without and with the plug, respectively. They provided a final assessment of the device.

RESULTS

Two of the 7 patients with congenital imperforate anus discontinued use because of pain and discomfort, 1 had a decrease in soiling episodes and 4 achieved full continence and needed no diapers while using 2 plugs daily (range 1 to 4). All patients preferred the smaller plug. Two of the 9 patients with spina bifida always lost the plug within 1 hour after introduction, 5 had a decrease in soiling episodes but continued to need diapers and 2 achieved full continence using 2 plugs daily (range 1 to 4). All patients preferred the larger plug.

CONCLUSIONS

The Conveen anal plug is an adjuvant treatment option for fecal incontinence in children with congenital imperforate anus or spina bifida, enabling a minority to stop using diapers. The Conveen anal plug is not a universal solution for fecal incontinence problems in these patients.

Imperforate anus, malrotation, and Hirschsprung's disease: a rare and important association

Imperforate anus and malrotation rarely occur together. The conjoint occurrence of these with Hirschsprung's disease is exceedingly rare, but failure to recognize its existence may lead to catastrophic results. We present a case in which awareness to this possibility caused early detection and avoidance of possible complications.

Infrared spectrophotometry of intraluminal meconium calculi in a neonate with imperforate anus and rectourethral fistula

BACKGROUND/PURPOSE

Intraluminal meconium calculi are a rare cause of neonatal abdominal calcifications in patients with anorectal malformations. To investigate their pathogenesis, we performed infrared spectroscopic analysis of meconium-calcified lesions.

METHODS

Meconium calculi were collected from the colostomy in a newborn patient with imperforate anus and rectourethral fistula. The potassium bromide method was employed to obtain the infrared absorption spectrum of the meconium calculi.

RESULTS

The wavelength pattern of the meconium calculi exhibited 4 specific peaks at 1570, 1390, 1105, and 1005 cm(-1) between 22% and 45% transmittance values. The unique absorption spectrum exclusively indicated ammonium hydrogen urate (C(5)N(5)O(3)H(7)), having the combined constituents of ammonium and uric acid.

CONCLUSIONS

These results suggest that the intraluminal meconium calculi were originally derived from meconium and fetal urine. The stasis of meconium passage and fetal urine mixing through the rectourethral fistula in a low-pH condition was deduced to be the main cause of this rare stone formation.

Progressive congenital torticollis in VATER association syndrome

STUDY DESIGN

A family study to reach the diagnosis of a multiple malformation syndrome.

OBJECTIVE

To determine the cause of torticollis, in a patient with the VATER association.

SUMMARY OF BACKGROUND DATA

The VATER association is a combination of vertebral anomalies, anal stenosis, tracheo-esophageal fistula, and radial anomalies. It needs a multidisciplinary approach with a major input from orthopedic surgeons. Torticollis in this condition has not been reported before.

METHODS

Detailed family history and radiologic study using plain radiographs and three-dimensional-reconstruction.

RESULTS

Bony abnormalities at the base of the skull and upper cervical vertebrae were found.

CONCLUSIONS

It is postulated that the bony abnormalities were the underlying cause of the neurologic problem.

Symptomatic anal anomalies in chromosome 22q11 deletion syndrome: a report of three patients

Deletion of chromosome 22q11 is a common genetic condition with varying clinical presentation ranging from neonatal fatality to patients whose presentation to medical services will be prompted after a few years by speech delay or mild developmental concerns. While most published data relating to patients with 22q11 deletions has focused on the "classical" presentation of the condition with cardiac manifestations, hypocalcaemia and velopharyngeal insufficiency, a much wider range of clinical presentations can characterise this syndrome. Anal anomalies, comprising imperforate anus and symptomatic anal stenosis, are a rarely described presentation of this multisystem disorder. In this report we document three patients presenting to paediatric services with symptoms attributed initially to symptomatic anal stenosis/atresia.

An exceptional type of anorectal malformation: anorectal atresia with posterior fistula in a newborn male

The authors report the case of a newborn male with an exceptional type of anorectal atresia with a fistula that passes posterior to the muscle complex and exits at a site just to the tip of the coccyx. This anorectal malformation was associated with other abnormalities including agenesis of the right kidney, pyelic dilatation of the left kidney, duplicity, and left megaureter. There was no defect in the spine. The anorectal malformation was managed successfully by a posterior sagittal approach according to the Pena procedure.