Abdominoperineal Pull-through Research Articles

Anorectal Malformation: Treatment by Laparoscopy

Anorectal abnormalities are classified into supralevator, intermediate, and infralevator types. According to the morphologic findings, different operative procedures are required for reconstruction. For a high anorectal abnormality, an abdominoperineal pull-through is often necessary. A 1-year-old girl with a high anorectal malformation was treated by laparoscopy. The rectal pouch and rectovaginal fistula were dissected, and the pull-through was done under visual control. The anastomosis was preformed extrabdominally at the perineum. There were no postoperative complications, and so far, continence is as good as that seen after conventional procedures.

Window rectostomy: an alternative method of fecal diversion for high anorectal malformations in males without a urinary fistula

This report analyzes our initial experience with window rectostomy (WR) as a new method of fecal diversion for high anorectal malformations (ARM) in 27 males without a urinary fistula between May 1994 and May 1998; total correction was achieved in two stages. In the first stage, during the neonatal period, the dilated rectum was exteriorized as a WR through the left lower abdomen. In the second, after 3-5 months an abdominoperineal pull-through (APPT) procedure was performed in which the window rectostomy was mobilized and taken down to form a new anus. The results were compared with cases of high ARM with urinary fistula that were managed in three stages, i.e., proximal sigmoid colostomy, APPT, and colostomy closure. All 27 cases showed satisfactory results without any mortality or major pelvic infection. The main advantages of WR are that it provides more functioning bowel length after diversion and avoids a colostomy-closure operation and repeated hospitalizations, thus reducing the total cost of treatment.

Coloplasty for congenital short colon

Seventy-two patients with complete short colon (CSC) were treated at the authors' institution between 1971 and 1994. Initially, one-stage coloplasty with abdominoperineal pull-through was performed in 10 neonates, with a 50% survival rate. The subsequent 62 patients had staged management in which a window colostomy was performed at the time of presentation. Of the 50 survivors in this group, 20 had coloplasty with a abdominoperineal or sacroabdominoperineal pull-through by June 1994. A protective ileostomy was done at the time of coloplasty in 10 patients, and was closed 6 to 12 weeks later. Two of the 20 patients who had staged reconstruction died because of complications; the others recovered well. The overall survival rate after coloplasty was 76.7%. Eighteen of the 23 survivors have had follow-up for up to 8 years. They have shown normal growth and good continence and have been free of significant long-term complications. The other 30 patients are awaiting definitive surgery. A staged management plan is advocated for complete short colon because it provides consistent results and good quality of life.

Results in the treatment of anorectal malformations with special regard to the histology of the rectal pouch.

The results of surgery for anorectal malformation (ARM) in 536 children treated between 1962 and 1993 are presented. Before 1985, patients underwent an abdominoperineal pullthrough for high and intermediate type of ARM, whereas cut-back procedures or perineoproctoplasty were performed in low type. Since 1985, we have changed our policy and performed a modified posterior sagittal anorectoplasty (PSARP) for intermediate type of ARM, eventually combined with an abdominal mobilization for high type. Perineoproctoplasty was reserved for low type of ARM. Data of 143 patients of Group 1 and 85 patients of Group 2 were available for follow-up. Continence was compared using a clinical score. Good or fair continence was found in 82% of patients operated on before 1985 (low type 85% good, 15% fair, intermediate type 17% good, 50% fair, high type 12% good, 37% fair), comparing to 93% in children treated after 1985 according to the new regimen (low type 88% good, 6% fair, intermediate type 59% good, 35% fair, high type 43% good, 47% fair). Liquid stools and inability to retain bowel contents were the main problem in the older series, whereas incontinence could often be attributed to constipation with overflow incontinence in the recently treated group of patients. Analysis of the innervation of fistula and distal rectal pouch in a prospective study comprising 40 of our most recent patients showed normal innervation in only 5% of patients, whereas 66% had neuronal intestinal malformations (NIM) including aganglionosis, NID and hypoganglionosis.(ABSTRACT TRUNCATED AT 250 WORDS)

The feasibility of laparoscopic swenson pull-through

The Swenson abdominoperineal pull-through is the authors' preferred treatment for children with Hirschsprung's disease. The present study was performed to determine whether this procedure's principles could be applied to laparoscopic techniques. The operations were performed in 13 mongrel dogs—first to optimize techniques, and second to observe postoperative function in the surviving animals. The authors found that the dog is a good model in which to study this procedure, and it appears possible to perform a satisfactory Swenson pull-through with the laparoscope.

Total Perineal Reconstruction After Major Obstetrical Injuries with Extensive Tissue Loss: A Report of 2 Cases

Major perineal injuries following obstetrical complications represent difficult problems of reconstruction. We describe 2 such patients with perineal injuries simulating infantile cloacas. Surgical repair using an abdominoperineal pullthrough procedure in 1 patient, and a Bricker loop type of repair in another resulted in successful restoration of function in both. The operative details and basis for the reconstruction are described.

Hydrometrocolpos in Neonate Due to Distal Vaginal Atresia

Hydrocolpos is the result of vaginal obstruction and can become an emergency in the newborn period. The treatment of imperforate hymen is well defined, but the treatment of vaginal atresia is more complex. We encountered two cases of hydrocolpos secondary to distal vaginal atresia, that were operated on in the first days of life. One baby had distal atresia without persistance of urogenital sinus. Surgery combining abdominal perineal approaches and a posterior vaginoplasty was carried out. The second baby had hydrocolpos with persistance of urogenital sinus. Drainage through the sinus was unsuccessful because the baby developed sepsis by trapping urine in the uterus. Finally an abdominoperineal vaginal pull-through was successfully done. The embryology and literature are reviewed. The classification, indications and surgical technique are discussed.

Operative failure and secondary repair in Hirschsprung's disease

The particular advantages of a variety of operations used in the treatment of Hirschsprung's disease have been widely described. Similar endeavors, guiding the surgeon should any one of these procedures fail, are decidedly less common. The referral of five children with operative failures led us to review our experience with secondary repairs in children with Hirschsprung's disease. The failed operations included the following pull-through procedures: Primary and secondary endorectal (4). Swenson (1), Duhamel (3), State-Rehbein (1) and an ileoproctostomy (1). Our review indicates that identical complications, such as anastomotic leaks, require different approaches depending on the primary procedure. Most patients with major complications did not respond adequately to diverting colostomies or direct operative repair alone, but required either a repetition of the primary procedure or a conversion into another type of abdominoperineal pull-through procedure. In three patients with a failed endorectal pull-through procedure, the anastomosis was taken down and the endorectal pull-through successfully repeated. Of three patients with a failed Duhamel procedure, one required a conversion into an endorectal procedure and another into a Swenson procedure. A failed ileoproctostomy and a failed State-Rehbein procedure were successfully converted into Duhamel pull-through procedures. Our experience with failed operative procedures for Hirschsprung's disease indicated that major complications after abdominoperineal pull-through procedures appear to be more common than reported, that secondary repair varies considerably and may require either a direct repair, a repetition of the original procedure or a conversion into another type of abdomino-perineal pullthrough, and that even major failures can be corrected successfully with the appropriate selection of the secondary procedure. The particular advantages of a variety of operations used in the treatment of Hirschsprung's disease have been widely described. Similar endeavors, guiding the surgeon should any one of these procedures fail, are decidedly less common. The referral of five children with operative failures led us to review our experience with secondary repairs in children with Hirschsprung's disease. The failed operations included the following pull-through procedures: Primary and secondary endorectal (4). Swenson (1), Duhamel (3), State-Rehbein (1) and an ileoproctostomy (1). Our review indicates that identical complications, such as anastomotic leaks, require different approaches depending on the primary procedure. Most patients with major complications did not respond adequately to diverting colostomies or direct operative repair alone, but required either a repetition of the primary procedure or a conversion into another type of abdominoperineal pull-through procedure. In three patients with a failed endorectal pull-through procedure, the anastomosis was taken down and the endorectal pull-through successfully repeated. Of three patients with a failed Duhamel procedure, one required a conversion into an endorectal procedure and another into a Swenson procedure. A failed ileoproctostomy and a failed State-Rehbein procedure were successfully converted into Duhamel pull-through procedures. Our experience with failed operative procedures for Hirschsprung's disease indicated that major complications after abdominoperineal pull-through procedures appear to be more common than reported, that secondary repair varies considerably and may require either a direct repair, a repetition of the original procedure or a conversion into another type of abdomino-perineal pullthrough, and that even major failures can be corrected successfully with the appropriate selection of the secondary procedure.

Congenital short colon with imperforate anus: A definitive surgical cure

Colonorraphy followed by abdominoperineal pull-through was performed in stages in a female baby with congenital short colon, imperforate anus and colovaginal fistula, with excellent outcome.

A reappraisal of surgical approaches for the definitive correction of imperforate rectum.

Abdominoperineal procedures for imperforate rectum have recently fallen into some disrepute, with a swing in favour of the sacrococcygeal approach. Based on experience with eight patients treated by abdominoperineal pullthrough, this paper seeks to recredit the abdominoperineal approach. Provided that the Rehbein technique of submucosal sleeve resection is supplemented by meticulous perineal dissection, satisfactory clinical results, with objective evidence of sphincter conservation, can be achieved. The relative merits and demerits of the abdominoperineal and sacrococcygeal approaches are reviewed, and reasons are given for preferring the more modern type of abdominoperineal approach.

Hyperchloremic acidosis as a complication of imperforate anus with recto-urinary fistula

Two cases of hyperchloremic acidosis occurring as a complication in infants with high Type III imperforate anus and rectourinary fistula have been reported and discussed. The possibility of this complication of electrolyte imbalance occurring where a colostomy, a fistula and urinary infection are present has been stressed. Factors in the pathogenesis of hyperchloremic acidosis have been outlined in relation to the anatomic abnormalities present in imperforate anus. Particular emphasis has been laid on the recto-urinary fistula through which retrograde flow of urine occurs into the large distal colostomy loops. While control of the imbalance can be helped by vigorous intravenous therapy, combined with an indwelling catheter, definitive treatment consists of elimination of the fistula surgically, either as a separate procedure or as part of an abdominoperineal pull-through.

Imperforate anus

The usual type of imperforate anus in the female baby can usually be repaired at six months of age by the perineal approach illustrated in this article. The usual type of imperforate anus in the male infant with a rectovesical fistula can be repaired at one to two days of age by an abdominoperineal pullthrough procedure. Both types of imperforate anus require special technic which is best accomplished by one experienced in these operations. Rapid transportation usually makes this possible. If delay is necessary in instances of the latter type, a transverse colostomy is much preferred to an inexperienced attempt at repair, as no amount of skill is likely to achieve good results with the second attempt.