Anal Stenosis Research Articles

Pyoderma Gangrenosum Is Associated With Increased Risk of Inflammatory Pouch-Related Complications: A Retrospective Cohort Study.

Pyoderma gangrenosum (PG) is a rare, neutrophilic dermatosis that is a well-established extraintestinal manifestation (EIM) of inflammatory bowel disease. The clinical implications of developing PG in patients with ulcerative colitis (UC) who undergo total proctocolectomy colectomy and ileal pouch anal anastomosis (TPC-IPAA) surgery remain unknown. Study participants were selected from patients enrolled in the Carlino Family Inflammatory Bowel and Colorectal Disease Biobank between 1998 and 2021 with a pre-colectomy diagnosis of UC and who underwent TPC-IPAA surgery. A retrospective study comparing patients with PG and those without PG was performed. The outcomes measured included the development of pouchitis, pouchitis classification, presence of pouch fistula, anal fistula, anal stenosis, and pouch failure. In this study, 357 IPAA patients were included, 10 of whom suffered PG. Patients with PG and without PG had similar demographics and clinical characteristics. Both groups had similar rates of pouchitis (80% in PG patients and 64% in patients without PG, P = .504). However, IPAA patients with PG had a higher risk of developing pouch fistula (50% vs 10%, P = .002), anal fistula (40% vs 12%, P = .031), and Crohn's-like disease of the pouch (70% vs 15%, P = .003) compared to patients without PG. Patients who developed PG prior to their first episode of pouchitis were more likely to eventually experience pouch failure (odds ratio: 20.7, 95% confidence interval: 3.9, 110.7, q = 0.003 after false discovery rate adjustment). Among UC patients who undergo TPC-IPAA surgery, the development of PG portends poor pouch outcomes and is predictive of pouch failure.

Functional constipation refractory to medical management: The anal sphincters are the problem

AimMost patients with functional constipation (FC) improve with medical treatment. For those with refractory symptoms, we propose a comprehensive and multidisciplinary work-up and decision-making approach to therapy. MethodsWe retrospectively reviewed patients referred to our center between 2019-2022 with suspected FC who had failed medical management. All patients underwent a contrast enema, anorectal manometry, examination under anesthesia, rectal biopsy (if needed), and botulinum toxin injection (as indicated). Results54 patients were evaluated using our algorithm. One was found to have anal stenosis on exam. The rectoanal inhibitory reflex (RAIR) was normal in 41(76%) patients and unable to be elicited in 12(22%). Two (17%) patients without a RAIR had Hirschsprung Disease (HD) and underwent a pull-through. 10(83%) with no RAIR had normal biopsies and were managed successfully with laxatives. Of the 41 patients with a normal RAIR, 14(34%) had high resting pressures (external sphincters) or non-relaxing (internal) sphincters and received botulinum toxin. 8(57%) of them were emptying well after one month. 24 patients failed laxatives (with or without botulinum toxin injections) and then underwent a Malone procedure. 23(96%) of these patients improved with antegrade flushes. One patient (1/21, 4.1%) did not undergo Malone and instead underwent colonic manometry and a sigmoid resection, after which he emptied well. ConclusionWe propose a systematic multidisciplinary approach for constipated patients who failed medical management starting with assessment of anal sphincters. This allows for targeted adjustment of laxative regimen, use of botulinum toxin to the internal and/or external anal sphincter and antegrade flushes via a Malone. Level of evidence levelIV

Complicated Diverticulitis and Pelvic Radiation Leading to Colonic Stricture, Colorectal Fistula, and Anal Stenosis.

The purpose of this case is to highlight a rare case of sigmoid colon-to-rectum fistula. A 66-year-old man with a history of pelvic radiation and diverticulosis presented to the emergency department with a 3-week history of abdominal pain and watery diarrhea. Computed tomography (CT) imaging was significant for a sigmoid-to-rectum fistula with sigmoid stricture. The patient underwent a laparoscopic colectomy with end colostomy. Pathology revealed perforated diverticulitis. To date, there have been no cases reported in literature describing sigmoid-to-rectum fistula. In conclusion, it is important to consider the development of complex diverticular disease in patients with history of pelvic radiation.

Anal Stenosis: House Flap Anoplasty.

Division of Colon and Rectal Surgery, University of Massachusetts Chan Medical School, Worcester, Massachusetts Funding/Support: None reported. Financial Disclosures: None reported. Correspondence: Justin Maykel, M.D., 67 Belmont St. Ste 201, Worcester, MA, 01605. Email: [email protected]. Twitter: @justinmaykel

A Study of the Clinical Profile and Management of Children With Anorectal Malformations.

Introduction The diagnosis of anorectal malformations (ARMs) antenatally is rare, and most of these cases are diagnosed in theneonatal period. The defects range from easily treated minor anomalies with good prognosisto those that are difficult and complex. The associated anomalies in these malformations are important determinants for the prognosis and outcome of these cases. Material and methods The present study was carried out in the department of pediatric surgery in a tertiary care institute. Patients presenting with ARMs in the neonatal period, those reported for definitive surgery, and patients for colostomy closure surgery were included. Patients who died before surgical treatment were excluded from the study. Convenience sampling of 100 patients who met the inclusion criteria was performed until the sample size was reached. Results Out of 63 cases of high variety, 84.12% were males and 15.87% were females. Out of 37 patients of low variety, 43.24% were males and 56.75% were females.The anomaliesof the urogenital system were present in 22 (34.92%) out of 63 cases of high ARMs and 10 (27.02%) out of 37 cases of low ARMs. In the male patients,anocutaneous fistula was in 16 (23.18%) of cases. Out of 31 females in the present study, anorectal agenesis with anovestibular fistula was seen in 19 (61.29%) cases. In the early complications, significant bleeding and urethral injury were seen in one (2.63%) patient each. However, among thelatecomplications, anal stenosis, mucosal prolapse, and wound infection were seen in seven (18.42%), five (13.15%), and four (10.52%) patients, respectively. Conclusion A holistic approach to the management of ARMs is needed with a long-term goal of achieving urinaryand fecal continence with good quality of life.The outcome of surgery is dependent on the specific type of malformation, but the results are better when intervention is done early.

The anatomy and physiology of the ileal pouch and its relevance to pouch dysfunction.

For the last 40years, the ileal pouch-anal anastomosis has been used in patients with ulcerative colitis, familial adenomatous polyposis, and occasionally severe constipation to reconstruct the gastrointestinal tract after proctocolectomy. Although the procedure has generally been successful in helping patients avoid an ileostomy, it has come with its own set of problems. These include complications of the surgery such as fistulas and bowel obstruction, persistent inflammation of the pouch known as pouchitis, and functional problems related to the lack of expulsive peristalsis in the pouch. It is this last group of problems that is exacerbated by a poor diet, ill-advised anti-diarrheal medications, anal stenosis and pouch twists. As a consequence, patients with pouch problems are frequently referred for radiologic evaluation, with pouchography, defecation studies, and small bowel imaging commonly requested. In this review, the basic anatomy and physiology of the ileal pouch are discussed to provide a logical baseline against which to measure the anatomy of pouches and its relationship to the symptoms of pouch dysfunction.

Indocyanine green fluorescence imaging localization: A helpful addition to laparoscopic dissection and division of rectourethral fistulae

BackgroundRectourethral fistulae (RUF) are the most prevalent type of anorectal malformations in boys, with various surgical treatment methods investigated in recent years. Currently, research is focused on preventing urethral damage or urethral diverticulum formation caused by imprecise dissection during the laparoscopically assisted anorectal pull-through (LAARP) technique. This study aimed to determine the efficacy of indocyanine green (ICG) fluorescence imaging to improve the localization and separation of the RUF during laparoscopic surgery. MethodsICG was intrarectally injected through a pre-inserted gastric tube at the distal enterostomy port to locate the fistula. This retrospective analysis included children with RUF who were treated surgically with ICG fluorescence imaging localization-assisted LAARP between January and June 2022. We investigated the patient demographics, perioperative conditions, and subsequent follow-up results. ResultsFour patients underwent ICG-assisted LAARP. Their median age was 80 days (range, 63–120) and the median duration of each procedure was 145 min (range, 120–165). Postoperatively, the duration of catheter retention and hospital stay was eight days. The children's prognosis was based on the follow-up outcomes of gastrointestinal, urinary tract function, and imaging examination. None of the included patients was diagnosed with urinary diverticulum, urinary tract injury, anal stricture, or rectal prolapse. ConclusionsInjection of ICG at the end of the rectum during LAARP surgery is a feasible adjunct for locating the RUF, providing a greater degree of accuracy for laparoscopic separation and resection of fistulae, thereby decreasing the risk of urological complications.

Efficacy of Harmonic Scalpel Versus Bipolar Diathermy in Hemorrhoidectomy: A Systematic Review and Meta-Analysis of Nine Randomized Controlled Trials.

Hemorrhoidectomy is one of the most common surgical interventions to remove the third and fourth degrees of prolapse hemorrhoid. We carried out this systematic review and meta-analysis of the randomized controlled trials (RCTs) to comprehensively evaluate the efficacy of harmonic scalpel (HS) versus bipolar diathermy (BD) methods in terms of decreasing intraoperative and postoperative morbidities among patients undergoing hemorrhoidectomy.Suitable citations were found utilizing digital medical sources, including the CENTRAL, Web of Science, PubMed, Scopus, and Google Scholar, from inception until December 2022. Only RCTs that matched the inclusion requirements were selected. We used the updated Cochrane risk of bias (ROB) tool (version 2) to assess the quality of the involved citations. The Review Manager (version 5.4 for Windows) was used to perform the pooled analysis. Data were pooled and reported as mean difference (MD) or risk ratio (RR) with a 95% confidence interval (CI) in random-effects models. Overall, there was no significant difference between HS and BD in terms of decreasing intraoperative morbidities like operative time, intraoperative blood loss, mean duration of hospital stay, and mean duration of first bowel movement (P>0.05). Similarly, the rate of postoperative complications like pain, bleeding, urinary retention, anal stenosis, flatus incontinence, and wound edema; was similar in both groups with no significant difference (P>0.05). In conclusion, our pooled analysis revealed there was no substantial difference between HS and BD in terms of intraoperative and postoperative endpoints. Additional RCTs with larger sample sizes are needed to consolidate the power and quality of the presented evidence.

HAEMORRHOIDECTOMY : ULTRASONIC SCALPEL VERSUS DIATHERMY CAUTERY

INTRODUCTION Haemorrhoids are the most common anorectal disease seen in age group between 45-50 years. Milligan Morgan haemorrhoidectomy is the gold standard operative procedure for grade 3 and grade 4 haemorrhoids.In the last decade high frequency sound wave energy ultrasonic scalpel is used to cut and coagulate tissues in Milligan-Morgan haemorrhoidectomy. OBJECTIVE Our aim is to do a comparative study between the outcomes of a Milligan Morgan haemorrhoidectomy by using ultrasonic scalpel versus diathermy cautery. MATERIALS AND METHODS This is a prospective comparative randomized study done over a period of 6months (April 2022-September 2022) at GGH Vijayawada. 60 patients of age group 45-65 years. They were randomly divided into 2 groups of 30 each. Group A – Underwent haemorrhoidectomy with diathermy cautery Group B- Underwent haemorrhoidectomy with harmonic scalpel. RESULTS Patients who underwent harmonic scalpel haemorrhoidectomy have statistically signicant P value in post operative pain , post op urinary retention and anal stenosis. CONCLUSION Harmonic scalpel is better than diathermy in having relatively less post operative pain and early resumption of daily activities and less occurrence of urinary retention and anal stenosis

P155 Natural history of anal stricture in pediatric-onset Crohn’s disease: a two-decades population-based study

Abstract Background The natural history of anal stricture complicating pediatric-onset Crohn’s disease (CD) is poorly known. The aims of this study were: to determine in a population-based study the risk of anal stricture in pediatric-onset CD; to identify risk factors for anal stricture; and to evaluate the natural history of anal stricture at the population level. Methods All patients with a diagnosis of CD made before the age of 17 years between 1988 and 2011 in a population-based registry were followed retrospectively until 2013. A specific collection of additional data was performed in patients with anal stricture at diagnosis or during follow-up. Variables collected included: proctological examination, diagnostic management and treatment. Multivariate Cox models were used to identify factors associated with anal stricture. Results Among the 1,007 included CD patients (females, 451 (44.8%); median age at diagnosis 14.4 years (IQR, 12.0-16.1), median follow-up 8.8 years (IQR, 4.6-14.2)), only one (0.1%) had anal stricture at diagnosis while 26 (2.6%) presented anal stricture during follow-up. Cumulative incidence of anal stricture at 5 and 10 years after diagnosis was 0.6% (CI95%, 0.1-1.1) and 1.4% (CI95%, 0.5-2.3), respectively. Among the 27 patients with anal stricture, 25 (92.6%) had already at least one episode of anal ulceration or fistulizing perianal CD (pCD). In multivariable analysis, the presence of extra-intestinal manifestations (Hazard Ratio (HR) 2.2, CI95% 1.0-4.8, p=0.027), colonic location (L1 vs L3 HR 0.0 (-); L2 vs L3 HR 1.2, CI95% 0.6-2.7, p=0.006) and history of fistulizing pCD (HR 9.9, CI95% 4.3-22.8, p<0.0001) were significantly associated with anal stricture. Eleven (41%) patients needed at least one dilation. After a median follow-up of 16.9 years (IQR, 11.5-20.2), healing of anal stricture was observed only once. One patient (3.7%) presented an anal cancer 7 years after the diagnosis of anal stricture. Nine (33.3%) patients needed a stoma. Among them, 8 already had a fistulizing pCD and 4 needed an abdominoperineal amputation. Anal stricture was significantly associated with an increased risk of stoma (HR 5.8, CI95% 2.3-14.3), p=0.0002). Conclusion Anal stricture is a rare event in pediatric onset CD, occurring in 1.5% of patients over a 10 year-period after diagnosis. However, anal stricture had a negative impact on disease prognosis with a five-fold increase of the risk of stoma.

Ten-year multicentric retrospective analysis regarding postoperative complications and impact of comorbidities in hemorrhoidal surgery with literature review.

Hemorrhoidal disease (HD) is considered a low-severity pathology by both general population and physicians, but the lengthy conservative therapy and postoperative complications suggest otherwise. To assess the effectiveness of different treatment options, both conservative and surgical, in contrast with some preexisting comorbidities. We conducted a retrospective, 10-yearlong study between January 2011 and December 2021 in two surgical centers, a private and a state-owned hospital. We compared the efficacy and safety of several treatment options, such as open hemorrhoidectomy, stapled hemorrhoidopexy, rubber band ligation and infrared coagulation in terms of complication rates and types and their correlation with different preexisting comorbidities such as inflammatory bowel disease (IBD), use of anticoagulant medication (AM) and liver cirrhosis. We also conducted a 20-years long PubMed research (1.263 articles) for relevant comparisons. Our study recorded 10940 patients with HD, 10241 with conservative and 699 with surgical treatment. Out of these, the male-to-female ratio of 1.3, and a peak in age distribution between 59 and 68 years old (32% of patients). For the entire study, we recorded a 90% incidence of immediate pain, immediate bleeding in 1.5% (11 cases), delayed bleeding in 1.0% (7 cases), and 0.6% surgical site infections. Urinary retention was also present, with 0.2% of patients, anal stricture in 1% and fecal incontinence for 0.5% of patients (4 cases). We recorded no severe complications such as Fournier`s gangrene or rectovaginal perforations. IBD accounted for 6% of the patients, with ulcerative colitis in 12% and Chron`s disease in 10.5%. 6.6% of the patients had AM, determining 4% immediate and 2% delayed bleeding, in surgically treated patients. Our study determined that most common complications (pain, urinary retention, bleeding, and stricture) are correlated with each surgical technique and pre-existing comorbidities.

Selection of operative approach in children with Currarino syndrome

To summarize the experience of surgical treatment of children diagnosed with Currarino syndrome, with an emphasis on the selection of an optimal operative approach. The clinical materials of patients diagnosed with Currarino syndrome were recorded. Special attention was given to the operative management, particularly the different routes for operation. The type of ARM was the critical point. The Rintala score was used for the evaluation of bowel function. The medical records of 26 patients were reviewed. Seven were male, and 19 were female, with a mean age of 19.38 ± 13.80months. The standard posterior sagittal approach (SPS) group included three perineal fistulae, one anal stenosis, one retraction of the rectum after anoplasty for vestibular fistula, one ARM with no fistula, one rectourethral fistula, and one cloaca. In the limited posterior sagittal approach (LPS) group, there were 13 perineal fistulae, one displacement of the rectum, and one retraction of the rectum after anoplasty for the vestibular fistula. In addition, the transanal approach (TA) and anterior sagittal approach (AS) were also used. The mean follow-up time was 39.48 ± 26.84m. The Rintala score was 16.74 ± 2.93. For a perineal fistula, SPS or LPS should be used to reach anoplasty and remove the presacral mass. For a vestibular fistula, the AS or LPS should be chosen. For anal stenosis, SPS or LPS should be used.

Minimally Invasive Procedure for Haemorrhoids: A Retrospective Observational Study

Introduction: The Minimally Invasive Procedure for Haemorrhoids (MIPH), also known as Stapled Haemorrhoidopexy (SH), has gained significant recognition and praise within the surgical community due to its speed and minimal postoperative pain. It was initially believed to have superior postoperative outcomes, resulting in reduced morbidity and mortality rates compared to traditional procedures. However, long-term follow-up data has now revealed previously undocumented sequelae and complications associated with SH. Aim: To share authors’ experience with SH, including patient demographics, operative details, recurrence rates, and postoperative complications, in a tertiary corporate teaching hospital. Materials and Methods: The present retrospective observational study was conducted at the Department of General Surgery and Advanced Laparoscopic Surgery, Dr. LH Hiranandani Hospital, Powai, Mumbai, Maharashtra, India. The study utilised data from the outcomes of SH performed by a single surgeon for Grade II and III haemorrhoids over a 15-year period, from December 2007 to December 2022. Data was extracted from the hospital’s Electronic Medical Records (EMR) and supplemented with information obtained through a telephonic questionnaire. A standard, prevalidated, semi-structured case record proforma was used for data collection. The parameters under study included donut completeness, haemorrhage, faecal urgency, urinary retention, anal stenosis, postoperative pain scores, return to work, and recurrence. Proportions, percentages, and means were calculated and reported for different groups. Results: A total of 245 patients were enrolled in the study. The average pain score at 12 hours postoperatively was 4, which decreased to 2 by day 10. Recurrent disease was observed in 16 patients (6%) at three months and in 24 patients (10%) at six months. Conclusion: The SH demonstrated advantages over conventional open surgery by causing significantly lower postoperative morbidity. However, its recurrence rates were slightly higher.

Closure of Fistula-in-Ano Using a Radial-Emitting Laser Probe: Initial Experience in Lagos, Nigeria.

Fistula-in-ano treatment has remained quite challenging with high failure rates and a potential for damage to the anal sphincteric complex leading to flatal or faecal incontinence. The treatment of fistula-in-ano using the fistula laser closure (FiLaC) as a minimally invasive, sphincter-saving procedure for complex disease has recently been documented. This review aimed to report the outcome of using it at the Lagos University Teaching Hospital. The procedures were performed with a radially emitting laser fibre from Biolitec AG-CeramOptec (Bonn, Germany). The duration of symptoms, type of fistula, duration of the procedures, and postoperative complications were evaluated. Eleven male patients had laser fistula-in-ano closure. The age range was 33-51 years, with a median age of 39 years and an interquartile range (IQR) of 37-47 years. Five patients were noted to have high fistula/e, whereas six had low fistula/e, seven had a single tract each, and three had three tracts each. The duration of surgery ranged, approximately from 3 to 60 min, with a median of 19 min and IQR of 9-33 min. Postoperative pain was mild in all patients and were all discharged as day case. There was no postoperative wound infection, anal incontinence, anal stenosis, and subcutaneous abscess. However, there was a recurrence in two patients. FiLaC has been demonstrated to be a reliable and safe sphincter-saving procedure for treating fistula-in-ano even for complex and high fistulae that is feasible in our subregion.

Challenges and Prospects of Laser Haemorrhoidoplasty in a Low Resource Setting: The LUTH Experience.

Haemorrhoids are the most common condition of the anal canal causing significant disability. Traditional excisional haemorrhoidectomy and its various modifications, while effective, may be attended by severe postoperative pain and other complications. Laser haemorrhoidoplasty is reported to be effective with fewer complications and shorter hospital stay. The aim of this study was to report the outcome of intrahaemorrhoidal coagulation with 1470-nm diode laser at the Lagos University Teaching Hospital. The procedures were performed with a radially emitting laser fibre from Biolitec AG-CeramOptec (Bonn, Germany). The duration of symptoms, grade of the haemorrhoids, duration of the procedures, and postoperative complications were evaluated. Eleven patients had laser haemorrhoidoplasty. There were seven males and four females. The age range was 23-71 years, with a median age of 47 years and an interquartile range (IQR) of 28-57 years. Duration of surgery ranged from 20 to 90 min, with a median of 33 min and IQR of 25-53 min. Postoperative pain was mild in eight patients and moderate in three. Ten patients were discharged as day cases and one 3 days later due to spinal anaesthesia-related headache and acute urinary retention. One patient later had an anal ulcer probably due to too much energy delivered during the procedure, this was managed conservatively. There was no postoperative wound infection, anal incontinence, anal stenosis, subcutaneous abscess, and fistula or recurrence. The advantages of laser haemorrhoidoplasty make it a readily acceptable form of treatment for haemorrhoids in our setting.

An Unusual External Genital Lesion and its Treatment- A Case Report

Lesions around the external genitalia are embarrassing, physically, socially, and emotionally depressing. Patients generally present late for treatment. Here, the authors describe a case of 32 years old female patient, who presented with multiple giant warts-like lesions involving the external genitalia since past 6 months. Any presence of pain, bleeding from the lesion, or alteration in bowel, bladder, or menstrual habits were denied. Lesion posed diagnostic and therapeutic challenges. She underwent resection of the lesion with reconstruction using a bilateral gluteal fasciocutaneous flap and split skin graft with diversion sigmoid colostomy. She further developed anal stricture and subcutaneous fistula, requiring anal dilatation and seton placement. After a brief period of Keigels’s exercises and anal dilatation, she underwent a reversal of sigmoid colostomy. The patient had to undergo staged surgeries to restore near normal external genitalia. This case is an unusual presentation of a genital lesion which was treated with a multidisciplinary team approach to restore her anatomy.

Gastric Outlet Obstruction Secondary to Incarcerated Stomach in Parastomal Hernia

Gastric outlet obstruction due to an incarcerated stomach in a parastomal hernia is extremely rare. Here, we present the management of such a case with a review of the literature. A 79-year-old woman presented with a 3-week history of postprandial vomiting and associated parastomal and epigastric pain. She had a loop colostomy created for severe fecal incontinence secondary to anal stenosis. Imaging revealed a large parastomal hernia with an incarcerated gastric antrum. She was initially managed nonoperatively with a nasogastric tube. She underwent a semi-elective open Sugarbaker mesh repair of the parastomal hernia with good results. Gastric outlet obstruction secondary to incarceration of the stomach in a parastomal hernia is uncommon. A conservative approach with nasogastric tube decompression is a reasonable initial approach in a patient who is not critically unwell, which allows time for consideration of different parastomal hernia repair techniques.

Evaluation of Patients With Congenital Anal Stenosis, Single Center Study.

Evaluation of Patients With Congenital Anal Stenosis, Single Center Study.

Cisternostomy In Lipomyelomeningocele Without Hydrocephalus: A Case Report

Introduction: Spinal dysraphisms can be classified as either open or closed dysraphisms. Closed spinal dysraphisms such as lipomyelomeningocele, diastematomyelia, and spina bifida occulta have no exposed neural tissue and are accompanied by cutaneous markers in 43%–95% of cases, and include lesions such as subcutaneous masses, capillary hemangioma, dimples, and hairy nevus. These cutaneous markers can be used to recognize cases in an asymptomatic neonate. LMMC can be associated with additional pathologies, including Chiari malformation type 1 (13%), spina bifida (14.4%), split cord malformations (3.1%), associated dermal sinuses (3.1%), dermoid or epidermoid cysts (3.1%), diastematomyelia (3.1%), terminal hydromyelia (3.1%), anal stenosis (1.0%), and Down syndrome (1.0%). Case Report: A year old girl, came to our department with chief complaint of lump on the back since the patient was born. No history of increased intracranial pressure was complained. On physical examination, there is no maceration on the lump, and there is no sign of ruptured lump on the back. Patient also has active motoric on all extremity. We diagnosed the patient with spina bifida. We did CT scan of the head to rule out hydrocephalus and MRI for the confirmation of spina bifida. Excision of cele was done. Postoperatively, there is an increased of csf leak of the patient from the excised cele and we decided to do cisternostomy. After cisternotomy, there is no increased of leakage and patient also have good motoric function. Patient was treated in our outpatient clinic and has good recovery after surgery. Discussion: Lipomyelomeningocele is a rare but complicated defect, lying in the spectrum of occult neural tube defects. It is actually a form of occult spinal dysraphism in which a subcutaneous fibrofatty mass traverses the lumbodorsal fascia, causes a spinal laminar defect, displaces the dura, and infiltrates and tethers the spinal cord. Spinal lipomas and LMMCs are frequently associated with cutaneous and musculoskeletal abnormalities in addition to sensorimotor deficits and urological dysfunction. Cutaneous lesions include subcutaneous lipomas, capillary hemangiomas, complex dimples, and hypertrichosis, whereas complex malformations, such as dermal appendages, are rare. Magnetic resonance imaging is useful in demonstrating the presence of a fatty mass and cord tethering. Surgical objectives in a lipomyelomeningocele repair include removal of the adipose mass, identification of the defect in the lumbosacral fascia for release of the tether, possible release of the filum terminale, preservation of neural elements, and prevention of retethering of the spinal cord. After operation for lipomyelomeningocele, the cord may not be completely untethered, or after a short period may retether Discussion: Cisternostomy may be done in cases of spina bifida without hydrocephalus in our experience

Outcomes after Surgical Treatment for Rectal Atresia in Children: Is There a Preferred Approach? A Systematic Review.

Rectal atresia (RA) affects only 1 to 2% of all children with anorectal malformations. No consensus on optimal treatment strategy is yet achieved. Therefore, the aim of this systematic review is to summarize all surgical interventions for RA and outcomes described in the current literature. A literature search was conducted in PubMed, Embase, Web of Science, and Cochrane Library on January 24, 2022. All studies describing treatment for RA in children (< 18 years) were included. Operation technique and postoperative complications were listed. Only descriptive analysis was anticipated. Quality of the studies was assessed using Johanna Briggs Institute critical appraisal checklist for case reports and series. The search yielded 6,716 studies of which, after duplicate removal, 4,028 were excluded based on title and abstract screening. After full-text assessment, 22 of 90 studies were included, yielding 70 patients. Posterior sagittal anorectoplasty (PSARP) and pull-through were most performed (43/70 and 18/70 patients, respectively). Four patients experienced postoperative complications: anal stenosis (n = 1), anastomotic stenosis (n = 2), and death due to a pulmonary complication (n = 1). In the low-quality literature available, most patients with RA are treated with PSARP or pull-through technique. A low complication rate of both has been described but follow-up was often not mentioned. Larger well-designed studies should be performed to determine optimal treatment strategy for children with RA. This study reflects level of evidence V.