Repair Of Anorectal Malformations Research Articles

Comparison of the PCPLC Database to NSQIP-P: A Patient Matched Comparison of Surgical Complications Following Repair of Anorectal Malformation

BackgroundAnorectal malformations (ARM) are rare and heterogenous which creates a challenge in conducting research and offering recommendations for best practice. The Pediatric Colorectal and Pelvic Learning Consortium (PCPLC) was formed in 2016 to address this challenge and created a shared national data registry to collect information about pediatric colorectal patients. There has been no external validation of the data collected. We sought to evaluate the database by performing a patient matched analysis comparing 30-day outcomes identified in the PCPLC registry with the NSQIP-P database for patients undergoing surgical repair of ARM. MethodsPatients captured in the PCPLC database from 2016 to 2021 at institutions also participating in NSQIP-P who underwent ARM repair younger than 12 months old were reviewed for 30-day complications. These patients were matched to their NSQIP-P record using their hospital identification number, and records were compared for concordance in identified complications. ResultsA total of 591 patient records met inclusion criteria in the PCPLC database. Of these, 180 patients were also reviewed by NSQIP-P. One hundred and fifty-six patient records had no complications recorded. Twenty-four patient records had a complication listed in one or both databases. There was a 91 % concordance rate between databases. When excluding complications not tracked in the PCPLC registry, this agreement improved to 93 %. ConclusionIncluding all patients evaluated for this subpopulation, a 91 % concordance rate was observed when comparing PCPLC collected complications to NSQIP-P. Future efforts can focus on further validating the data within the PCPLC for other patient populations. Level of evidenceV.

Functional Outcomes of Patients Who Underwent Anorectal Malformation Repair Using MRI Guidance

BackgroundDespite the initiation of minimally invasive laparoscopic techniques, the majority of patients who undergo anorectal malformation repair still experience functional bowel issues in childhood, including constipation and fecal incontinence. In this study, we evaluate the functional outcomes of a procedure in which magnetic resonance imaging guidance is used during initial laparoscopic repair to better locate the epicenter of the sphincter muscle complex and pelvic floor with the goal of more accurate placement of the neoanus and improved functional outcomes. MethodsA retrospective chart review evaluated demographic, operative, and outcome details for patients who underwent this procedure. A telephone survey was employed to determine levels of social continence using the validated Baylor Continence Scale and to determine what type of bowel management is used. ResultsTwenty-six patients were included. Median age at operation was 7 months, and median age at follow-up was 4 years old, with a range of 1–9. Bowel management regimen results revealed that 19 % (n = 5) use no bowel management regimen, 58 % (n = 15) use laxatives only, and 23 % (n = 6) use enemas. Enema use was not associated with different spine or sacral anomalies (p = 0.77). Fifteen patients (58 %) answered the Baylor Continence Scale questions and had a median score of 14. No difference was found in scores when accounting for lesion level (p = 0.43), quality of needle placement (p = 0.46), or quality of sphincter muscles (p = 0.75). ConclusionsUsing MRI guidance in the repair of anorectal malformations shows promise in both the qualitative and quantitative functional outcomes of this complex patient population. Level of EvidenceLevel III.

Rectal Prolapse Following Repair of Anorectal Malformation: Incidence, Risk Factors, and Management

BackgroundThe incidence and optimal management of rectal prolapse following repair of an anorectal malformation (ARM) has not been well-defined. MethodsA retrospective cohort study was performed utilizing data from the Pediatric Colorectal and Pelvic Learning Consortium registry. All children with a history of ARM repair were included. Our primary outcome was rectal prolapse. Secondary outcomes included operative management of prolapse and anoplasty stricture following operative management of prolapse. Univariate analyses were performed to identify patient factors associated with our primary and secondary outcomes. A multivariable logistic regression was developed to assess the association between laparoscopic ARM repair and rectal prolapse. ResultsA total of 1140 patients met inclusion criteria; 163 (14.3%) developed rectal prolapse. On univariate analysis, prolapse was significantly associated with male sex, sacral abnormalities, ARM type, ARM complexity, and laparoscopic ARM repairs (p < 0.001). ARM types with the highest rates of prolapse included rectourethral-prostatic fistula (29.2%), rectovesical/bladder neck fistula (28.8%), and cloaca (25.0%). Of those who developed prolapse, 110 (67.5%) underwent operative management. Anoplasty strictures developed in 27 (24.5%) patients after prolapse repair. After controlling for ARM type and hospital, laparoscopic ARM repair was not significantly associated with prolapse (adjusted odds ratio (95% CI): 1.50 (0.84, 2.66), p = 0.17). ConclusionRectal prolapse develops in a significant subset of patients following ARM repair. Risk factors for prolapse include male sex, complex ARM type, and sacral abnormalities. Further research investigating the indications for operative management of prolapse and operative techniques for prolapse repair are needed to define optimal treatment. Type of studyRetrospective cohort study. Level of evidenceII.

Post-Operative Anorectal Manometry in Children following Anorectal Malformation Repair: A Systematic Review.

Despite surgical correction, children with anorectal malformations may experience long-term bowel dysfunction, including fecal incontinence and/or disorders of evacuation. Anorectal manometry is the most widely used test of anorectal function. Although considerable attention has been devoted to its application in the anorectal malformation cohort, there have been few attempts to consolidate the findings obtained. This systematic review aimed to (1) synthesize and evaluate the existing data regarding anorectal manometry results in children following anorectal malformation repair, and (2) evaluate the manometry protocols utilized, including equipment, assessment approach, and interpretation. We reviewed four databases (Embase, MEDLINE, the Cochrane Library, and PubMed) for relevant articles published between 1 January 1985 and 10 March 2022. Studies reporting post-operative anorectal manometry in children (<18 years) following anorectal malformation repair were evaluated for eligibility. Sixty-three studies were eligible for inclusion. Of the combined total cohort of 2155 patients, anorectal manometry results were reported for 1755 children following repair of anorectal malformations. Reduced resting pressure was consistently identified in children with anorectal malformations, particularly in those with more complex malformation types and/or fecal incontinence. Significant variability was identified in relation to manometry equipment, protocols, and interpretation. Few studies provided adequate cohort medical characteristics to facilitate interpretation of anorectal manometry findings within the context of the broader continence mechanism. This review highlights a widespread lack of standardization in the anorectal manometry procedure used to assess anorectal function in children following anorectal malformation repair. Consequently, interpretation and comparison of findings, both within and between institutions, is exceedingly challenging, if not impossible. Standardized manometry protocols, accompanied by a consistent approach to analysis, including definitions of normality and abnormality, are essential to enhance the comparability and clinical relevance of results.

Simple division of rectourethral fistula as an alternative to ligation during laparoscopic repair of anorectal malformation

BackgroundVarious techniques are described to manage the rectourethral fistula during laparoscopic repair of anorectal malformation (LAARP). The fistula can be ligated with sutures, clips, staplers, or simply divided flushed with the urethra.ObjectiveThe aim of our study is to share our experience of simply dividing the rectourethral fistula during LAARP without ligation.Patients and methodsA retrospective chart review conducted between January 2005 and April 2020 including male children with rectourethral fistula. The fistula was managed by laparoscopic simple division without ligation along with temporary urinary diversion.ResultsTwenty-six patients were included. None of the patients had short- or long-term urinary complications due to the technique used. All patients had a regular follow-up for a minimum of 1 year.ConclusionSimple division of rectobulbar or rectoprostatic fistula is a safe, easier alternative to ligation of the fistula during laparoscopic repair of ARM.

Comparative study between one-stage versus three-stage repair of anorectal malformation with recto-vestibular fistula

BackgroundThis is a retrospective comparative study that aimed to compare the short-term and intermediate-term outcomes of the one-stage and three-stage repair in the treatment of female neonates with a recto-vestibular fistula. Female patients who were presented with recto-vestibular fistula between 2017 and 2020 have been included in the study, and they were divided into two groups. Group A is the group of patients that underwent one-stage repair, and Group B is the group of patients that underwent three-stage repair. Short- and intermediate-term outcomes were recorded in both groups and the results were compared.ResultsThirty-six female infants with recto-vestibular fistula were included in our study divided into two groups. Group A included 20 cases for whom we performed one-stage posterior sagittal anorectoplasty, and Group B also included 16 cases for whom the three-stage repair was done. The results showed that the three-stage repair had lower hospital stay (8 days) than the one-stage repair (15 days), and the three-stage repair has lower rates of wound infection, wound dehiscence, and recurrence than the one-stage repair.ConclusionThe three-stage repair of anorectal malformations in females with recto-vestibular fistula is a safer technique, has lower rates of complications, and achieves comparable functional results to the one-stage repair.

Levobupivacaine plasma concentrations following repeat caudal anesthetics.

A single caudal anesthetic at the start of lower abdominal surgery is unlikely to provide prolonged analgesia. A second caudal at the end of the procedure extends the analgesia duration but total plasma concentrations may be associated with toxicity. Our aim was to measure total plasma levobupivacaine concentrations after repeat caudal anesthesia in infants and to generate a pharmacokinetic model for prediction of plasma concentrations after repeat caudal anesthesia in neonates, infants and children. Infants undergoing definitive repair of anorectal malformations or Hirschsprung's disease received a second caudal anesthesia at the end of the procedure. Total levobupivacaine concentrations were assayed 3-4 times in the first 6h after the initial caudal. These data were pooled with data from four studies describing plasma concentrations after levobupivacaine caudal or spinal anesthesia. Population pharmacokinetic parameters were estimated using nonlinear mixed-effects models. Covariates included postmenstrual age and body weight. Parameter estimates were used to simulate concentrations after a repeat levobupivacaine 2.5mg kg-1 caudal at 3 or 4h following an initial levobupivacaine 2.5mg kg-1 caudal. Twenty-one infants (postnatal age 11-32 weeks, gestation 37-39 weeks, weight 5.2-8.6kg) were included. The measured peak plasma concentration after repeat caudal levobupivacaine 2.5mg kg-1 4 h after initial caudal was 1.38 mg L-1 (95% prediction interval 0.60-2.6mg L-1 ) and 3 h after initial caudal was 1.46 mg L-1 (0.60-2.80)mg L-1 . Simulation of total plasma concentrations in neonates (7kg, 57 weeks postmenstrual age) given caudal levobupivacaine 4 h after the initial caudal were 1.76 mg L-1 (0.68-3.50) mg L-1 if 2.5mg kg-1 levobupivacaine was used and 0.88 mg L-1 (0.34-1.73)mg L-1 if 1.25 mg kg-1 of 0.125% levobupivacaine was used. In simulated older children (20 kg, 6 years), the mean maximum concentration was 1.43 mg L-1 (0.60-2.70)mg L-1 if 2.5mg kg-1 levobupivacaine was repeated at 3h. Repeat caudal levobupivacaine 2.5mg kg-1 at 3h after an initial 2.5mg kg-1 dose does not exceed the concentration associated with systemic local anesthetic toxicity. In 2.5% of simulated neonates (weight 3.8kg, PMA 40 weeks), repeat caudal anesthesia demonstrates broaching of the lower concentration limit associated with toxicity at both 3 and 4 h after initial caudal.

Stricture rate in patients after the repair of anorectal malformation following a standardized dilation protocol.

The aim of this study was to determine and analyze the stricture rate in patients who underwent a PSARP or PSARVUP and followed a postoperative protocol of anal dilation (Fig. 1). A retrospective review of patients with anorectal malformation (ARM) who underwent a primary PSARP or PSARVUP from February 2016 to October 2021 was performed. Data collected included patients' demographics, type of ARM, age at the time of operation, postoperative complications, with emphasis on whether there were any strictures or any difficulties during dilations, and on follow-up. During the surgical repair, emphasis was placed on preserving the blood supply of the bowel and performing a tension-free bowel-to-skin anastomosis. Eighty-four patients met the inclusion criteria. Forty-four patients were females: 21 recto-perineal fistula, 12 cloaca, 9 recto-vestibular fistula, one imperforate anus without fistula, and one patient had a complex anorectal and vaginal malformation with an anal stricture and a rectovaginal fistula. Forty patients were males: 14 recto-perineal fistula, 11 recto-urethral bulbar fistula, 6 recto-urethral prostatic fistula, 6 imperforate anus without fistula, and 2 bladder neck fistula. One patient had an anal stenosis with sacral agenesis, without a presacral mass. Patient ages ranged from 0 to 79months (mean 7.5months, median 5months) at the time of surgery. Follow-up time ranged from 7 to 73months (mean 38months, median 35months). No patient suffered of a postoperative anal stricture. Six patients suffered of a rectal prolapse that required a surgical repair. Post-operative anal stricture after PSARP and PSARVUP can be avoided with proper surgical technique and postoperative care. Namely, by preserving adequate blood supply of the bowel and avoiding tension at the anoplasty, and by adhering to a structured protocol of anal dilations.

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

IntroductionThe objective of this study is to assess the postoperative outcomes of single-stage repair of anorectal malformations with vestibular (VF) or perineal fistula (PF) and early initiation of postoperative feeding. MethodsA retrospective review of patients undergoing single-stage repair of isolated low anorectal malformations (VF and PF) from 2017 to 2020 was conducted. All patients underwent an anterior anoplasty with complete mobilization of the rectal fistula, or posterior sagittal anorectoplasty (PSARP), without protective colostomy. The variables examined include age, timing of postoperative feeding initiation, length of stay (LOS), and complications. ResultsNineteen patients with VF or PF underwent a single-stage repair. 12/19 (63%) patients were female. All 7 males and 9/12 females had a PF. The range of age at surgery was 2 days to 3 years with median age of 92 days [IQR 1,3: 9,193]. The median postoperative day for initiation of feeds was day 0 [IQR 1,3: 0,1] and median LOS was 1 day [IQR 1,3: 1,4.5]. 18/19 (95%) patients were evaluated in follow-up and there were no wound infections, wound dehiscences, or recurrent fistulas. Within 90 days postoperatively, no patients were seen in the emergency department for postoperative issues. Within 6 months, 2/19 (11%) patients required an unplanned return to the operating room for anal dilation. ConclusionIn single-stage repair of isolated low anorectal malformations, VF and PF, early initiation of postoperative feeding is safe, results in a short length of stay, and does not lead to increased wound complications. Early enteral feeding eliminates the need for parenteral nutrition and central venous access, and their associated complications. Level of evidenceLevel IV

AB023. SOH22ABS138. Sacral and tibial nerve stimulation in the treatment of faecal incontinence post repair of anorectal malformation (ARM): a systematic review of the literature

AB023. SOH22ABS138. Sacral and tibial nerve stimulation in the treatment of faecal incontinence post repair of anorectal malformation (ARM): a systematic review of the literature

To Study the Outcome of Posterior Sagittal Anorectoplasty in Anorectal Malformations

Aim: To assess the effectiveness of posterior sagittal anorectplasty for the repair of anorectal malformations in terms of postoperative complications and functional outcomes. Study design: Descriptive prospective study. Place and duration of study: Sahiwal Teaching Hospital, Sahiwal. From 1st January 2016 to 31st December 2019. Methodology: Forty-two children with high/intermediate anorectal malformations, who underwent posterior sagittal anorectoplasty, were included in the study. Patients with low variety anorectal malformations, recto vestibular/ano vestibular fistula, persistent cloaca and patients with sacral dysraphism, spinal dysraphism, myelomeningocele spina bifida occulta and menifesta were excluded. Demographic information included age, gender, weight, type of anorectal malformation, type of surgery performed, operation time and hospital stay. Immediate post-operative complications were also noted. Bowel habits, constipation and faecal incontinence were evaluated in all patients during the follow up period. Results: Thirty-one (73.80%) were males and 11(26.19%) were females and mean age was 1.72 years. The mean weight at the time of operation was 11.00 kg. High variety anorectal malformations were 14(33.33%) and intermediate were 28(66.66%). Rectourethral fistula 25(59.52%) was most common variety seen in males. Recto bulber urethral fistula in 17(40.47%) and recto prostatic urethral fistula in 8(19.04%) patients were seen. Anal agenesis without fistula 7(16.66%) was most common anomaly in females. Overall complication rate was 15(35.71%). Constipation 11(26.19%) was most common post-operative complication. True fecal incontinence was seen in 3(7.14%) patients. Strong and effective squeeze of anal sphincter was seen in 39 (92.85%) patients and satisfactory bowel habits were present in 37 (88.08%) patients. Conclusion: Posterior sagittal anorectplasty is a useful procedure in the management of high/intermediate anorectal malformations, precise identification and reconstruction of muscle complex result in good anatomical and functional outcome. Immediate post-operative complication rate is also low. Keywords: Anorectal malformations, Posterior Sagittal Anorectoplasty, Postoperative complications, Functional outcomes

Cardiorespiratory performance and locomotor function of patients with anorectal malformations

The aim of this study was to assess whether adolescents following anorectal malformation repair have a decreased cardiorespiratory performance capacity and impaired motor skills. All eligible children treated for ARMs between 2000 and 2014 were invited to participate in a prospective study consisting of a clinical examination, evaluation of Bowel function and Quality of Life, spirometry, spiroergometry and assessment of the motor activity. The results were compared to a healthy age- and sex-matched control group. There was no statistically significant difference in height, weight, BMI, muscle mass or body fat percentage between the study and the control group. Nine out of 18 patients (50%) had an excellent functional outcome with a normal Bowel Function Score. Spirometry revealed no significant differences between ARM patients and controls, four patients showed a ventilation disorder. Spiroergometry revealed a significantly lower relative performance capacity and the overall rating of the motor activity test showed significantly decreased grades in ARM patients. ARM patients were affected by an impaired cardiopulmonary function and decreased motor abilities. Long-term examinations consisting of routine locomotor function evaluation and spiroergometry are advisable to detect impaired cardiopulmonary function and to prevent a progression of associated complications and related impaired quality of life.

An overview of opioid usage and regional anesthesia for patients undergoing repair of anorectal malformation.

The recent opioid crisis in the USA compelled us to evaluate our practice of opioid use for postoperative pain management and the influence of regional anesthesia on opioid requirement in patients undergoing repair of anorectal malformations. A retrospective chart review was performed evaluating patients who underwent posterior sagittal anorectoplasty (PSARP) and posterior sagittal anorecto-vagino-urethroplasty (PSARVUP), with or without laparotomy, between January 2016 and March 2020. Morphine milligram equivalents per kilogram (MME/kg) were calculated. IRB approval was obtained for this study. A total of 105 surgical patients had either a PSARP (74 without laparotomy, 10 with laparotomy) or PSARVUP (13 without laparotomy, 8 with laparotomy). Regional anesthesia included epidurals, transversus abdominis plane block, caudal block or paravertebral catheters. Of the PSARP patients, 4 without laparotomy and 7 with laparotomy received regional anesthesia. For PSARVUP with laparotomy, 4/8 received regional. 44% of PSARP patients without laparotomy did not require opioids postoperatively. The MME/kg required exponentially increased for patients over the age of 5 who underwent PSARP. Regional anesthesia is a useful modality for pain control for PSARP/PSARVUP with laparotomy, decreasing the opioid usage, but it is unnecessary for the already low opioid requirements, in patients younger than 5years of age, without laparotomy.

Biofeedback on Faecal Incontinence After Anorectal Malformations Repair: Effects Through Four Months: A Randomized Controlled Trial

Background. Surgical repair for anorectal malformation in children had post-operative unsatisfactory results as children still suffering from faecal incontinence. Objective. The effect of Biofeedback in treating children fecal incontinence after anorectal malformations repair was investigated. Methodology. A randomized controlled trial design was conducted in the Pediatric hospital, Mansoura University. Forty-eight children with postsurgical anorectal malformations repair were assessed for eligibility. Forty children (twenty-two boys and eighteen girls) underwent simple randomization into two matched groups, control and study group. The anal function was assessed by Anorectal manometry and faecal incontinence was evaluated by Baylor social continence scale. Measurements were done before and after two months of intervention, and after four months of follow-up. Result. There was statistically significant improvement in maximal resting anal pressure, maximal voluntary contraction pressure, voluntary contraction time, the threshold of rectal sensation, maximal tolerable rectal volume and Baylor social continence scale (P &lt; 0.05) for biofeedback group after two months of intervention and four months of follow-up in comparison with conservative treatment. Conclusion. Biofeedback improved faecal incontinence after ARM repair and had an intermediate follow up effect in conjunction with conservative interventions.

Contrast enhanced colostography: New applications in preoperative evaluation of anorectal malformations

IntroductionUnderstanding details of anatomic relationships between the colon and surrounding structures is a critical piece of preoperative planning prior to surgical repair of anorectal malformations (ARMs).Traditional imaging techniques involve ionizing radiation, distention of the rectum with supraphysiologic intraluminal pressures, and sometimes require sedation. Recent developments in the field of contrast agents have allowed the emergence of an ultrasound-based technique that can avoid these requirements while continuing to provide high resolution structural information in three dimensions. MethodsFourteen children (13 male, 1 female, age 1–11 months) with ARMs underwent contrast enhanced colostography (ceCS) in addition to traditional preoperative imaging techniques to delineate anatomic relationships of pelvic structures. ResultsceCS and traditional imaging yielded concordant anatomic information, including structural relationships and fistulous connections, in 10/14 patients (71%). ceCS detected fistulous connection in 2/13 patients (15%) that were not seen by traditional imaging. Ultrasonography failed to detect the fistulous connection in one patient. ConclusionsceCS is a safe, effective and flexible method for defining important structural information in ARM patients. When compared with traditional methods, it provided equivalent or superior results 93% of the time and bears consideration as a standard tool in preoperative planning for this population. Type of StudyRetrospective Comparative Study. Level of EvidenceLevel III.

Comparing 30-day outcomes between early versus delayed repair of anorectal malformations with perineal or rectovestibular fistulas: An analysis of the ACS NSQIP-Pediatric database

BackgroundAnorectal malformations (ARMs) have a wide spectrum of presentation ranging from mild defects with perineal fistulas to more severe defects requiring complex management. A primary repair of ARMs with perineal or rectovestibular fistulas has been shown to have good outcomes. However, the timing of the reconstruction is still debated. The aim of this study is to investigate the safety of early versus delayed repair. MethodsThis study was performed using data from the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) from 2012 to 2017. Patients who underwent repair of anorectal malformation with perineal or vestibular fistula were included in the study. Patients with associated diagnosis for Hirschsprung disease, cloaca, rectal prolapse or stenosis, bladder exstrophy, and tracheoesophageal fistula were excluded. 30-day postoperative outcomes included wound and nonwound complications, readmissions, and reoperations. Outcomes were compared by early (≤7 days of age) versus delayed repair (6 weeks to 8 months). ResultsA total of 291 patients were included, with 66 in the early and 231 in the delayed group. Patients in the early group were more likely to be male (68.2% vs 31.8%; p < 0.01) and have cardiac risk factors (71.2% vs 49.4%, p < 0.01). The mean operative time was significantly shorter in the early group (90.1 vs 129.6 min; p < 0.01). 30-day complications were not statistically significant between the two groups (p = 0.76). After multivariate analysis, timing of repair did not affect 30-day complications (p = 0.15). ConclusionOur study shows that early repair of low anorectal malformations with a perineal or vestibular fistula appears to be associated with no increase in risk of postoperative complications as compared to delayed repair. At present, the decision remains dependent on the surgeon's experience and judgment. Level of evidenceLevel III. Retrospective comparative study.

Vacuum-assisted closure (VAC) prevents wound dehiscence following posterior sagittal anorectoplasty (PSARP): An exploratory case–control study

BackgroundWound dehiscence (WD) of the anocutaneous anastomosis or perineal body after posterior sagittal anorectoplasty (PSARP) is common. We aimed to evaluate the efficacy of a perineal vacuum-assisted closure (VAC) for prevention of WD following repair of anorectal malformations (ARM) with rectoperineal and rectovestibular fistula. MethodsA retrospective dual-center case–control study of children undergoing PSARP without colostomy between 2011 and 2019 was performed. The VAC group received preoperative bowel preparation (PBP), postoperative application of a VAC, loperamide (only Location A), intravenous antibiotics (IA), and total parenteral nutrition (TPN). The non-VAC group underwent PBP, loperamide (Location A), IA, and TPN without VAC. Primary outcome was WD at the anocutaneous anastomosis or reconstructed perineal body within the first 14 days after surgery. ResultsThe study population included 18 patients (VAC group) and 20 children (non-VAG group) with rectoperineal and rectovestibular fistula. The incidence of WD in the VAC group was 0% compared to 25% in the non-VAC group (0/18 vs. 5/20, p = 0.04). No VAC related complications occurred. ConclusionPostoperative application of a VAC embedded in a perioperative treatment protocol has the potential to prevent wound dehiscence of the neoanus and reconstructed perineal body following PSARP. Type of studyCase–control study. Level of evidenceLevel III.

Correlation of anorectal manometry measures to severity of fecal incontinence in patients with anorectal malformations \u2013 a cross-sectional study

Anorectal malformations (ARM) are a spectrum of anomalies of the rectum and anal canal affecting 1 in 2500 to 5000 live births. Functional problems are common and related to the type of ARM and associated malformations. We aimed to evaluate the results of Three-dimensional High Resolution Anorectal Manometry (3D-HRAM) in long-term follow-up after surgical correction of ARM with special reference to fecal incontinence. Twenty-one patients with anorectal malformations and primary repair at our center consented to participate in the study. Pressures of the anal sphincter muscles and defects were addressed by 3D-HRAM. Fecal incontinence and disease-specific quality of life were evaluated by the Fecal Incontinence Quality of Life score and Wexner incontinence score respectively. The study was approved by the Committee in Health Research Ethics and the Danish Data Protection Agency. Median age was 22(12–31) years and 13(67%) participants were females. Sphincter defect was present in 48% (N = 10) of participants. Participants with sphincter defects had significant higher Wexner score and size of sphincter defects and mean anal squeeze pressure were correlated to Wexner score. Participants with or without sphincter defects did not differ on manometry parameters including resting anal and squeeze pressure or disease-specific quality of life. In a study of the long-term outcome after repair of anorectal malformations we found a higher Wexner incontinence score in the presence of an anal sphincter defect and the size of the defect and mean anal squeeze pressure were correlated to the Wexner incontinence score.

Long term bowel function after repair of anorectal malformations in Uganda

BackgroundAnorectal malformations (ARMs) are common congenital anomalies cared for at Mulago Pediatric Surgery Unit (PSU), similar to other sites in the region. All patients undergo staged repairs and complete treatment at older ages compared to high-income countries (HICs). This is the first study to examine long-term bowel function in our patients and compare with HICs. MethodsA retrospective cohort study was conducted of all children 3–12 years old with ARMs who had repair between January 2012 and June 2017 and who completed surgical repair at least 6 months prior to the study. Bowel function was measured using the fecal continence scoring system derived from Rintala and Lindahl (1995). As in prior studies, patients were classified by score into four categories: Poor (6–9); Fair (9–11); Good (12–17); and Normal (18–20). ResultsMedian follow up was 2 years post stoma closure. Long-term bowel function was Normal/Good in 65% (C.I 27, 45), and Fair/Poor 35% (C.I 55, 73), with soiling in 49% (C.I 40, 59), constipation in 23% (C.I 16, 32); and incontinence in 39% (C.I 30, 39). There was no statistically significant association between bowel function and multiple demographic, social, and clinical factors. Median age at completion of treatment (stoma reversal) was 2.3 years old, and median duration of colostomy (interval between stoma placement and takedown) was 1.8 years. ConclusionDespite definitive repair at older age and almost two years of living with a stoma, our patients achieve fair long-term bowel function. Nonetheless, improved follow up and timely management of complications may improve outcomes soiling, incontinence and constipation. Level of evidenceLevel II.

The effectiveness of digital anal dilatation in preventing anal strictures after anorectal malformation repair

BackgroundAnal dilatation is performed after repair of anorectal malformations(ARMs) and is vital in prevention of anal stricture formation. The ideal protocol utilizes Hegar dilators. In our setup, few parents will acquire Hegar dilators for home based anal dilatation but majority will use fingers as an alternative. The basis of this study was to determine the effectiveness of digital anal dilatations in preventing anal strictures. Materials and methodsThis was a descriptive cross-sectional study carried out at Kenyatta National Hospital (KNH) which recruited children post ARM repair undergoing digital anal dilatation. The diameters of the digits used for anal dilatation were assessed for adequacy using the desired anal size as a reference point. The main outcome variable was the presence of anal strictures. Data were entered in a data collection sheet and analyzed by use of SPSS (V.21.0 Chicago, Illinois). Chi-square test and Fisher's exact test were used to ascertain association among variables. A P-value of less than 0.05 was considered statistically significant. Results50 patients with ARM post repair were recruited in the study. The rate of occurrence of anal stricture was 22%. Among the participants with anal strictures, only 27% were compliant to the dilatation regimen while 73% reported noncompliance. The mean diameter(mm) of the dilating digits at the level of the middle phalanx was Index finger (15.4 ± 0.58), middle finger (15.2 ± 0.61), ring finger (14.2 ± 0.71), small finger (12.5 ± 0.91) and thumb (17.6 ± 0.78). 46% of the participants were dilated with appropriately sized digits. The remainder had dilatations done with larger (22%) or smaller digits (32%). Notably, anal strictures occurred in participants who were dilated with inappropriately sized digits (P = 0.001). ConclusionDigital anal dilatation is safe and effective as a mode of anal dilation in the setting of compliance to a strict dilatation protocol, daily frequency of dilations and use of appropriately sized digits. Owing to the variability in the finger size, we recommend that digits be calibrated and education given to the caregivers on the use of the appropriately sized digit. Level of evidenceTreatment study.Level III.