Laparoscopically Assisted Anorectal Pull-Through versus Posterior Sagittal Anorectoplasty for High and Intermediate Anorectal Malformations: A Systematic Review and Meta-Analysis.

Yijiang Han,Zhongrong Li,Shikun Guo,Xiangbo Yu,Zhaobo Xia,Shian-Ying Sung

doi:10.1371/journal.pone.0170421

Abstract

ObjectiveAnorectal malformations (ARMs) are one of the commonest anomalies in neonates. Both laparoscopically assisted anorectal pull-through (LAARP) and posterior sagittal anorectoplasty (PSARP) can be used for the treatment of ARMs. The aim of this systematic review and meta-analysis is to compare these two approaches in terms of intraoperative and postoperative outcomes.MethodsMEDLINE, Embase, Web of Science and the Cochrane Library were searched from 2000 to August 2016. Both randomized and non-randomized studies, assessing LAARP and PSARP in pediatric patients with high/intermediate ARMs, were included. The primary outcome measures were operative time, length of hospital stay and total postoperative complications. The second outcome measures were rectal prolapse, anal stenosis, wound infection/dehiscence, anorectal manometry, Kelly's clinical score, and Krickenbeck classification. The quality of the randomized and non-randomized studies was assessed using the Cochrane Collaboration's Risk of Bias tool and Newcastle-Ottawa scale (NOS) respectively. The quality of evidence was assessed by GRADEpro.ResultsFrom 332 retrieved articles, 1, 1, and 8 of randomized control, prospective and retrospective studies, respectively, met the inclusion criteria. The randomized clinical trial was judged to be of low risk of bias, and the nine cohort studies were of moderate to high quality. 191 and 169 pediatric participants had undergone LAARP and PSARP, respectively. Shorter hospital stays, less wound infection/dehiscence, higher anal canal resting pressure, and a lower incidence of grade 2 or 3 constipation were obtained after LAARP compared with PSARP group values. Besides, the LAARP group had marginally less total postoperative complications. However, the result of operative time was inconclusive; meanwhile, there was no significant difference in rectal prolapse, anal stenosis, anorectal manometry, Kelly's clinical score and Krickenbeck classification.ConclusionFor pediatric patients with high/intermediate anorectal malformations, LAARP is a better option compared with PSARP. However, the quality of evidence was very low to moderate.

Highlights

Anorectal malformations (ARMs), including imperforate anus, occurs in approximately 1 in 4000–5000 liveborn infants [1]
Less wound infection/dehiscence, higher anal canal resting pressure, and a lower incidence of grade 2 or 3 constipation were obtained after laparoscopically assisted anorectal pull-through (LAARP) compared with posterior sagittal anorectoplasty (PSARP) group values
Inclusion criteria were: (1) clinical trials comparing laparoscopically assisted anorectal pull-through and posterior sagittal anorectoplasty; (2) pediatric patients with high/intermediate anorectal malformations that were under 18 years old; (3) the study that was the most recent and the most complete among the multiple papers published by the same center

Summary

Introduction

Anorectal malformations (ARMs), including imperforate anus, occurs in approximately 1 in 4000–5000 liveborn infants [1]. Wingspread classification distinguishes high, intermediate and low ARM types, according to the relationship of the terminal rectum to levator ani [2]. Krickenbeck classification is based on previous experience, stressing the presence and position of fistula, considering bulbar fistulas and imperforate anus without a fistula as well as most vaginal fistulas as intermediate-type anomalies, and prostatic and bladder neck fistulas as hightype imperforate anus [3]. For selecting the surgical approach, the international Wingspread classification remains useful. Posterior sagittal anorectoplasty (PSARP) has gradually become the standard operation method for high/intermediate anorectal malformations in most pediatric centers since it was introduced by deVries and Peña in 1982 [4]. Poor functional outcomes are still observed after PSARP [5]. To avoid the adverse effects of open surgery, pediatric surgeons increasingly focus on laparoscopic techniques

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