Anorectal Reconstruction Research Articles

Preoperative fistula diagnostics in male anorectal malformations after colostomy: a single-center experience

BackgroundAccurate preoperative fistula diagnostics in male anorectal malformations (ARM) after colostomy are of great significance. We reviewed our institutional experiences and explored methods for improving the preoperative diagnostic accuracy of fistulas in males with ARMs after colostomy.MethodsA retrospective analysis was performed on males with ARMs after colostomy admitted to our hospital from January 2015 to June 2022. All patients underwent magnetic resonance imaging (MRI) and high-pressure colostogram (HPC) before anorectal reconstruction. Patients with no fistula as diagnosed by both modalities underwent a voiding cystourethrogram (VCUG). General information, imaging results and surgical results were recorded.ResultsSixty-nine males with ARMs after colostomy were included. Age at the time of examination was 52 ~ 213 days, and the median age was 89 days. The Krickenbeck classification according to surgical results included rectovesical fistula (n = 19), rectoprostatic fistula (n = 24), rectobulbar fistula (n = 19) and no fistula (n = 7). There was no significant difference in the diagnostic accuracy between MRI and HPC for different types of ARMs. For determining the location of the fistula, compared to surgery, HPC (76.8%, 53/69) performed significantly better than MRI (60.9%, 42/69) (p = 0.043). Sixteen patients diagnosed as having no fistula by MRI or HPC underwent a VCUG, and in 14 patients, the results were comfirmed. However, there were 2 cases of rectoprostatic fistula that were not correctly diagnosed.ConclusionHigh-pressure colostogram has greater accuracy than MRI in the diagnosis of fistula type in males with ARMs after colostomy. For patients diagnosed with no fistula by both methods, VCUG reduces the risk of false-negative exclusion, and rectoprostatic fistula should be considered during the operation.

Effects of extensive mobilization and tension anastomosis in anorectal reconstruction (experimental study).

Anorectoplasty and pull-through procedure can be performed with extensive mobilization or tension anastomosis, which can compromise bowel blood perfusion. We aimed to analyze the hypoxia biomarker values and histopathological findings in both conditions to correlate the occurrence of anal stenosis and defecation disorders in experimental models. We created anorectal reconstruction models with impaired vascularization of the anorectum (group I) and tension anastomosis (group II) in rats. A third group of animals underwent sham operation (group III) and another as controls (group IV). Hypoxia biomarker values were assessed in all groups. The histopathological changes on the postoperative days 3 and 35, anal stenosis and defecation disorders on day 35 were compared. Hypoxia biomarkervalues confirmed postoperative ischemia in groups I-III compared to control. Group I and II rats had a similarly pronounced ischemia with histopathologic changesin the anorectum on the postoperative day 3 and accompanied by severe fibrosis on day 35. Compared to the sham operation, bothgroupsshowed defecation disorders with significant anal stenoses. Extensive rectal mobilization to about the same extent as tension anastomosis has a major impact on postoperative rectal ischemia, resulting in severe fibrotic changes in the anorectum and defecation disorders in the long term.

Neonatal Ultrasound for Anorectal Malformations in Male Newborns Without Perineal Fistula: A Good Diagnostic Tool for A Safe One-Staged Surgery

Background/Purpose: The standard neonatal approach for a male newborn with an anorectal malformation (ARM) and no perineal fistula remains the opening of a diverting colostomy. Here we describe radiological improvements in neonatal ultrasound (US) that characterize the recto-urinary fistula and allow a direct anorectal reconstruction. Material and Methods: This is a descriptive report of radiological findings in neonatal ultrasound in all newborn male patients with an ARM, no perineal fistula and no colostomy, recruited over a 6-year period. A paediatric radiologist actively looked for recto-urinary fistulas and their relation to anatomical landmarks. These findings, along with the clinical status and associated anomalies, were considered to indicate a single-staged procedure. Results: From 28 neonates with ARM only three met the inclusion criteria. The first 2 cases showed a bulbar and prostatic fistula in US but with associated malformations and benefited from a colostomy. The third baby presented a bulbar fistula in the US, normal sacrum and no lifethreatening malformations and benefited from a singlestaged procedure. Conclusions: Neonatal perineal US can give the same anatomical information than the distal colostogram and leads to a safe single-staged procedure in expert teams, if there is a lack of associated life-threatening malformations.

Anus perinei ventralis in adulthood – case report

Anorectal malformations present atype of the most serious congenital malformations, either in terms of treatment or treatment outcomes. Anorectal atresia can be subdivided into three categories: the supralevator form, the intermediate type of atresia and the low translevator type. One of the clinical forms of low translevator type in girls is aperineal fistula opening just behind the vaginal entrance on the perineum, with afully developed sphincter complex dorsally from the fistula (so called anus perinei ventralis). The golden standard of surgical treatment of anus perinei ventralis in children is Peñasprocedure, which was used as aguideline for anorectal reconstruction in our adult patient, as well.

Composite Antropyloric Valve and Gluteus Maximus Muscle Wrap for Neoanal Reconstruction: Initial Results.

Severe fecal incontinence has a significant negative impact on patient well-being. Current surgical methods of total anorectal reconstruction to substitute a colostomy have suboptimal results. A composite graft using antropyloric valve transposition and gracilis wrap has been described with good outcomes. However, this procedure requires extensive training of patients. Gluteus maximus, an accessory muscle for continence, may be better suited for this purpose. The purpose of this study was to evaluate the outcomes of composite antropylorus-gluteus graft for intractable fecal incontinence. Patients underwent a 3-stage procedure: antropyloric transposition with diversion stoma followed by gluteus wrap. Stoma was closed after ensuring the anatomic and functional integrity of the graft. This study was conducted at a single tertiary care institution. Patients who were on permanent colostomy for intractable incontinence or would have had one after abdominoperineal resection were included. Endoultrasonography, MRI, loopogram, saline holding test, anal manometry, St. Mark's fecal incontinence score, and personal interviews were used for measurement. Eleven patients underwent the procedure with a median follow-up of 16 months (range, 13-34 mo). Digital rectal examination revealed a resting tone with a distinct squeeze provided by the composite graft. Radiological imaging confirmed healthy grafts. There was a significant improvement in mean anal manometry values (resting pressure: preoperative = 10.25 mm Hg vs postoperative = 20.45 mm Hg; squeeze pressure: preoperative = 22.63 mm Hg vs postoperative = 105.18 mm Hg) and mean incontinence score postprocedure (preoperative = 22.8 vs postoperative = 8.6). On personal interview, majority of the patients were continent and expressed satisfaction with the procedure. The study was limited by its small sample size with no control group. Composite graft in patients with intractable fecal incontinence can serve as a viable novel method for total anorectal reconstruction. However, it should only be recommended for a highly select group of individuals in a surveillance setting. Its long-term outcomes remain to be determined as well as its risk versus benefit.

Role of Routine Dilatations after Anorectal Reconstruction—Comparison of Two Tertiary Centers

Regular anal dilatations are commonly recommended in the postoperative management following posterior sagittal anorectoplasty (PSARP) in anorectal malformations (ARM). We hypothesized that routine postoperative dilatations may not affect surgical outcomes following PSARP. We compare surgical outcomes of routine postoperative dilatations versus no routine postoperative dilatations from two United Kingdom tertiary pediatric surgical centers. This is retrospective records review of patients undergoing definitive surgery for ARM in two tertiary surgical centers in the UK over 5 years. Center A used a protocol of routine postoperative dilatations, and center B used a protocol, which used dilatations only for clinical indications of stricture. Data collected included ARM type, operative procedures, and postoperative interventions. All post-operative interventions under general anesthesia (GA) were compared between groups. From 2011 to 2015, 49 procedures (46 PSARPs) were performed in center A and 54 (52 PSARPs) in center B. Median follow up period was 31 months (interquartile range [IQR] 18-48). The first postoperative anal calibration under GA was documented for 43 (86%) patients in center A and for 42 (78%) patients in center B. Following this, center A followed routine postoperative dilatation (RPD) at home, and center B reserved further dilatations for specific indications. RPD was performed for 100% of patients in center A versus 8% in center B. Further anal dilatations under GA were performed in 19 (38%) children in center A and in 17 (34%) children in center B (p = 0.68). In center A, 10 patients (22%) needed further surgery versus 14 (28%) in center B (p = 0.48). The use of routine postoperative dilatations does not significantly improve surgical outcomes following PSARP in ARM.

Anorectal Agenesis with Rectovaginal Fistula: A Rare/Regional Variant.

Aims and Objectives:The anatomical types of female anorectal malformation (ARM) are complex and include several rare and regional variants. The aim of this report is to highlight the diagnosis and management of cases of anorectal agenesis with rectovaginal fistula (RVF).Materials and Methods:This is a retrospective chart review of cases of RVF who underwent definitive surgery between November 2000 and September 2016 in a single institution.Results:Of the 244 female patients with anorectal anomalies treated in our institution over a 16-year period, there were 15 cases of RVF with anorectal agenesis giving it an incidence of 6%. All cases of RVF with anorectal agenesis presented with absence of anal opening, varying degree of abdominal distension, and history of passage of fecal matter per vaginum. The mean age of presentation was 3 months (newborn to 1 year). Sigmoid colostomy was done in 13 cases. Distal colostogram demonstrated high RVF which was further confirmed by examination under anesthesia (EUA) and endoscopy before definitive surgery. With the posterior sagittal approach, division of the RVF and anorectoplasty was possible in 14 cases; however, one patient required an abdominal mobilization of the colon for pull through due to a very short distal bowel segment. During a mean postoperative follow-up of 5 years, cosmetic and functional results were satisfactory.Conclusion:RVF with anorectal agenesis is a rare/regional variant of female ARMs. Clinical examination along with distal colostogram, EUA, and endoscopy clinches the diagnosis. Anorectal reconstruction by posterior sagittal anorectoplasty results in a satisfactory outcome.

The Practice of Anal Dilations following Anorectal Reconstruction in Patients with Anorectal Malformations: An International Survey.

Purpose The objective of this study was to investigate the current practices of anal dilations after anorectal reconstruction for anorectal malformations (ARMs) in different centers. Materials and Methods An online survey, consisting of 27 questions about the practice of anal dilations, was launched in March 2015 among 54 pediatric surgeons with expertise in colorectal surgery. The survey was divided into three sections. The first section included questions regarding the country of origin, the role in the department, the average number of ARM cases treated per year, and the surgical approach used to repair ARMs. The second section was accessible only for surgeons who perform anal dilations and enquired about their modality of performing anal dilations-their attitude toward complications such as rectal prolapse, bleeding, or perineal dehiscence occurring during dilations-and about the incidence of rectal prolapse and/or anal stenosis, which required surgical repair, in their series of patients with ARMs. The third section was accessible only for surgeons who do not perform anal dilations and enquired the incidence of rectal prolapse and/or anal stenosis that required surgical repair in their series of patients with ARMs. Results A total of 36 pediatric surgeons from 20 countries completed the survey. All participants performed anal dilations. Twenty-five (70%) surgeons performed the first dilation 14 days after anorectal reconstruction; 30 (83%) surgeons performed it in the outpatient clinic; 34 (94%) surgeons used metal dilators and 30 (83%) surgeons lubricated the dilator with an anesthetic/steroid-free ointment; 21 (59%) surgeons tailored the first dilator size to the specific anatomical features of each patient; 27 (75%) surgeons used 1-mm-diameter increments in the dilator size and 22 (61%) surgeons increased the size weekly; 16 (45%) surgeons followed up with the patients weekly until the proper dilator size was reached. This was determined according to Peña's protocol by 25 (70%) surgeons: 23(64%) surgeons initially performed dilations twice daily; 24(66%) surgeons tapered the frequency of dilations once the desired caliber was reached. No general agreement exists in the management of complications such as rectal prolapse, bleeding, or perineal dehiscence occurring during dilations. Incidence of rectal prolapse and anal stenosis was reported less than 5%, respectively, by 25(70%) and 29(81%) respondents. Conclusion Anal dilations for ARM are performed worldwide according to different modalities. Prospective and randomized clinical trials could be useful to establish a standardized protocol.

Dynamic article: composite antropyloric valve and gracilis muscle transposition for total anorectal reconstruction: a preliminary report.

Technique and functional outcomes of anorectal reconstruction using an antropyloric graft have been reported previously. This technique had reasonable initial outcomes but lacked voluntary function. We hereby report the initial results of patients who underwent gracilis muscle wrapping around the perineally transposed antropyloric valve in an attempt to improve voluntary fecal control. This study was conducted at a single tertiary care institution. Eight adult patients (7 men and 1 woman) with a median age of 38 years (range, 19-51 years) underwent this procedure. Seven patients already had anorectal reconstruction with a transposed antropyloric valve, and 1 patient with severely damaged anal sphincter complex underwent single-stage composite antropylorus transposition with a gracilis muscle wrap. The primary outcome measures were anatomical integrity and functional status of the composite graft in the perineum. No operative mortality or serious procedure-related morbidity occurred in any patient. The median postoperative resting pressure was 29 mmHg (range, 22-38 mmHg) and squeeze pressure was 72.5 mmHg (range, 45-267 mmHg). There was a significant improvement in the squeeze pressure following surgery (p = 0.039). Also, the St. Mark's incontinence scores significantly improved in all patients and varied between 7 and 9 (p = 0.003). The ability to defer defecation and the reduced frequency of leakage accidents were the prime reasons for improved postgraciloplasty outcomes in these patients. On personal interviews, all patients who underwent this procedure were satisfied with the results of their surgery. A longer follow-up with a larger sample size is required. Quality-of-life data have not been evaluated in this study. Gracilis muscle wrapping around a perineally transposed antropyloric valve is possible and improves the voluntary control and overall functional outcomes in a select group of patients with end-stage fecal incontinence requiring anal replacement (Supplemental Digital Content 1, http://links.lww.com/DCR/A173).

Anatomic basis of anorectal reconstruction by dynamic graciloplasty with pudendal nerve anastomosis.

Dynamic graciloplasty has been proposed for anal reconstruction, but this method has 2 major drawbacks. First, an electrical device is required for control of the gracilis. The anastomosis with the pudendal nerve will provide more physiological control. Second, the limitation in the mobility of the muscle flap results in wrapping the anal canal with the muscle's distal portion, which is tendonlike and inelastic. Enhancing the mobility of the muscle flap will enable wrapping with the proximal, muscle-like, and extensible portion, possibly providing better sphincteric function. However, the basis for such an operative method is lacking. The aim of this study is to provide the basis for the refined method of anal sphincter reconstruction by dynamic graciloplasty with pudendal nerve anastomosis and to verify the feasibility of lengthening the nerve to the gracilis muscle flap by dissecting into the muscle belly, detaching the gracilis muscle from its origin, and enhancing the mobility of the muscle flap. This is a retrospective, descriptive study. The results from the anatomical study on 9 cadavers are reported. Tension-free anastomosis of the pudendal nerve and nerve to the gracilis was successfully performed in all the 9 cases: in 2 cases, by lengthening the nerve. The detachment of the muscle origin improved the mobility of the muscle flap, and the more proximal portion could be used for wrapping the anal canal, as confirmed in 4 cases. The limited number of cases was a shortcoming of this study. By lengthening the nerve to the muscle, the gracilis can be used for anal sphincter reconstruction with pudendal nerve anastomosis, negating the need for an electrical device. By detaching the origin of the gracilis muscle, its proximal portion can be used to wrap the anal canal, possibly enabling a longer functional canal with stronger constricting force and better vascularity. These modifications to past methods may improve fecal continence after the operation.

Current aspects and future prospects of total anorectal reconstruction--a critical and comprehensive review of the literature.

Many rectal cancer patients undergo abdominoperineal excision worldwide every year. Various procedures to restore perineal (pseudo-) continence, referred to as total anorectal reconstruction, have been proposed. The best technique, however, has not yet been defined. In this study, the different reconstruction techniques with regard to morbidity, functional outcome and quality of life were analysed. Technical and timing issues (i.e. whether the definitive procedure should be performed synchronously or be delayed), oncological safety, economical aspects as well as possible future improvements are further discussed. A MEDLINE and EMBASE search was conducted to identify the pertinent multilingual literature between 1989 and 2013. All publications meeting the defined inclusion/exclusion criteria were eligible for analysis. Dynamic graciloplasty, artificial bowel sphincter, circular smooth muscle cuff or gluteoplasty result in median resting and squeezing neo-anal pressures that equate to the measurements found in incontinent patients. However, quality of life was generally stated to be good by patients who had undergone the procedures, despite imperfect continence, faecal evacuation problems and a considerable associated morbidity. Many patients developed an alternative perception for the urge to defecate that decisively improved functional outcome. Theoretical calculations suggested cost-effectiveness of total anorectal reconstruction compared well to life with a permanent colostomy. Many patients would be highly motivated to have their abdominal replaced by a functional perineal colostomy. Given the considerable morbidity and questionable functional outcome of current reconstruction technique improvements are required. Tissue engineering might be an option to design an anatomically and physiologically matured, and customised continence organ.

Modified H-pouch as an alternative to the J-pouch for anorectal reconstruction.

A modification is described of the J-pouch to facilitate ileoanal anastomosis in the presence of an anal or anovaginal fistula. The bowel is divided at the level of the apex of the J-pouch, the distal limb is advanced to project beyond the proximal limb by 3-5cm. The pouch is constructed by a side-to-side anastomosis to form the H-pouch with a distal ileal segment, which is passed through the anal canal to form an ileoanal anastomosis. The modification allows the treatment of anal and rectal disorders not resolvable by a usual J-pouch construction, as in cases where a rectal resection is needed for concomitant fistulation or destruction of the anal mucosa. The functional results are similar to those of the J-pouch, with no added postoperative morbidity. This technique helps to avoid permanent stoma in selected cases. The modified pouch is relatively simple to perform and can help the surgeon to address complex anorectal disorders.

Neuromodulation of perineally transposed antropylorus with pudendal nerve anastomosis following total anorectal reconstruction in humans.

We have reported perineal antropyloric segment transposition with its pudendal innervation as a replacement for anal sphincter. Our aim herein was to neuromodulate this segment by electrical stimulation. Eight patients with a permanent colostomy underwent perineal antropyloric segment transposition followed by neural anastomosis of its anterior vagus branch to pudendal nerve branch in the perineum. Perineal antropyloric graft was assessed for its functional integrity and electrophysiological effects. Nerve stimulation was done by surface stimulation technique, using a customized stimulation protocol for smooth muscle. Antral pressures were recorded on voluntary attempts and on nerve stimulation with simultaneous concentric needle electromyography of the perineal antropylorus. The antral segment showed slow spontaneous contractions (2-3/min) on digital examination, endoscopy, and electrophysiology. Stimulated antropyloric electromyography showed a latency of 2-5 s with a differential rise in amplitude (mean range 58.57-998.75 μV) according to the frequency of stimulation (range 10-150 Hz). An average latency of 10 s in relation to rise in the antral pressure was observed on pudendal nerve stimulation. Triggering of the intrinsic rhythm was observed in patients where it was initially absent. Voluntary attempts at contraction also showed a rise in perineally transposed antral pressure. Spontaneous rhythm, its generation after electrical stimulation, and response to voluntary contraction demonstrates the viability and functional reinnervation of the perineally transposed antropyloric segment. Rise in pressure on electrical stimulation shows evidence for its neuromodulation.

Modern management of anal incontinence.

Anal incontinence (AI) reflects the final common pathway of a multitude of aetiological factors and, as an underestimated clinical problem, it represents a major social and economic burden. Its epidemiology and objective assessment of the severity of the problem are discussed in this Special Edition by Nevler from Israel. In the 1980s, the management of AI included some form of sphincter repair or scaffold, as discussed by Pescatori and Pescatori, with the construction of a colostomy as the only other surgical option. The development of a series of complicated muscle transposition procedures ensued and was supplemented by electrical stimulation, following an improvement in our understanding of the basic functioning of the voluntary myocyte. These procedures are discussed by Barisic and Krivokapic. This approach was followed by the adoption, from urological practice, of an artificial bowel sphincter that could be used to augment a perineal colostomy, in some cases of total anorectal reconstruction, and in patients with complex congenital anomalies after failed reconstruction. Neither of these more complex approaches has effectively stood the test of time, resulting in high complication rates, and the frequent need for operative revision and ultimate explantation of the device. Given the costs (both financial and patient-related) of these more complex procedures, there are available today novel, specialized alternatives that are considered in this Special Edition. These include the use of a stoma for antegrade colonic irrigation, as discussed by Zbar (Israel), either alone or as part of a complex total anorectal reconstruction designed to augment a perineal colostomy. Also considered is the rediscovery of the use of a simple anal sling (previously used for rectal prolapse), as discussed by Devesa (Spain) and radiofrequency treatment of the anal canal as discussed by Felt-Bersma (Netherlands). The rise of primary internal anal sphincter dysfunction leading to troublesome faecal seepage was previously not amenable to therapy, with poor results from muscle plication; however, hope has arrived with the new implants—although prospective, randomized data are currently lacking concerning the ideal agent for use or the technical aspects of its optimal deployment. These issues are discussed by de la Portilla, who presents personal data from Spain. Lately, sacral neuromodulation (SNM) has become a first-line therapy in AI management in many cases, even in the presence of small defects of the external anal sphincter, which in the past would have been repaired at the outset. The 75% overall success rate of SNM, almost regardless of the aetiology of AI (success being defined as a 50% or greater reduction in incontinence episodes), appears to be maintained over prolonged, medium-term follow-up. The technique of SNM has become fairly standardized, with the ab initio use of a permanent lead and decisions on permanent stimulator implantation being made after an initial period of temporary stimulation. About 60% of patients progress to a permanent implant, although there are currently no clear prognostic factors that predict a successful temporary stimulation trial. The complication rate of SNM is very low, with Zbar presenting an algorithm of its postoperative troubleshooting when functional outcomes are suboptimal. Currently, however, the simpler (and cheaper) technique of peripheral posterior tibial nerve stimulation (PNS)—performed transcutaneously or percutaneously—is reserved for SNM failures, but its true role in the treatment algorithm remains to be determined. Latterly, some comparative studies have suggested that acupuncture may be equally efficacious, and future studies will define the role of these therapies in AI cases of differing severity and aetiology. It should not be forgotten that the first port of call in AI management involves conservative therapies and physical treatments that will substantially improve individual patient care, although the limited trial data show little improvement over placebo in terms of quality of life in collated patient cohorts. The conservative options in AI management are addressed by Dan Carter from Israel. Finally the cost of these therapies, both in terms of economic health burden and for individualized therapy, are considered by Edden (Israel) with an emphasis on the cost-effectiveness of neurostimulatory therapies. This Special Edition clearly outlines the place of established and newer therapies in the management of patients with AI. The future will better define the indications and contra-indications, particularly for stimulatory treatments, and may elucidate the supraspinal and central mechanisms of action of neuromodulatory methods.

The antegrade continence enema procedure and total anorectal reconstruction

Patients may present with anal incontinence (AI) following repair of a congenital anorectal anomaly years previously, or require total anorectal reconstruction (TAR) following radical rectal extirpation, most commonly for rectal cancer. Others may require removal of their colostomy following sphincter excision for Fournier's gangrene, or in cases of severe perineal trauma. Most of the data pertaining to antegrade continence enema (the ACE or Malone procedure) comes from the pediatric literature in the management of children with AI, but also with supervening chronic constipation, where the quality of life and compliance with this technique appears superior to retrograde colonic washouts. Total anorectal reconstruction requires an anatomical or physical supplement to the performance of a perineal colostomy, which may include an extrinsic muscle interposition (which may or may not be ‘dynamized'), construction of a neorectal reservoir, implantation of an incremental artificial bowel sphincter or creation of a terminal, smooth-muscle neosphincter. The advantages and disadvantages of these techniques and their outcome are presented here.

Anorectal reconstruction using graciloplasty after abdominoperineal resection: A review of the current literature and recommendations for the future

Background: Anorectal reconstruction with the gracilis muscle following abdominoperineal resection (APR) is an option for patients who do not want a permanent abdominal stoma. Despite some promising results, significant heterogeneity still exists in the method and timing of surgery, as well as the use of electrical stimulation. Aim: We review the literature so as to make the best recommendations for the use of this procedure. Method: Nine of the latest publications were reviewed looking at primary versus secondary reconstruction, use of electrostimulation, double versus single graciloplasty, surgical techniques, complications, functional outcomes, and patient selection. Conclusion: Graciloplasty should be performed as a delayed procedure about three years after APR so as to exclude those who develop recurrence or otherwise adapt well to the abdominal stoma. Single muscle graciloplasty can be performed with good results and an electrical stimulator should only be implanted if continence cannot be achieved after biofeedback training.

Neurovascular antropylorus perineal transposition using inferior rectal nerve anastomosis for total anorectal reconstruction: preliminary report in humans

Technical feasibility of inferior rectal nerve anastomosis to the anterior vagus branch of the perineally transposed antropyloric valve for total anorectal reconstruction has been previously demonstrated in cadavers. To the best of our knowledge, the present study is the first report of using this procedure in humans. Eight patients [mean age 35.5years (range 15-55years); (male/female=7:1)] underwent the procedure. The antropyloric valve with its anterior vagus branch was mobilized based on the left gastroepiploic arterial pedicle. The antral end was anastomosed to the distal colon. The anterior vagus nerve was anastomosed by epineural technique to the inferior rectal nerve in the perineum. A diverting proximal colostomy was maintained for 6months. Anatomical integrity of the graft (on magnetic resonance imaging scans), its arterial pedicle (on computed tomography angiogram) and neural continuity (on ultrasound and pyloric electromyography) were assessed. Functional assessment was performed using barium retention studies, endoscopy, manometry and fecal incontinence scores. Tension-free end-to-end anastomosis of the anterior vagus nerve to the right (n=7) and left (n=1) inferior rectal nerve was achieved. An intact left gastroepiploic pedicle, a healthy graft and neural continuity were visualized on perineal ultrasound. Electromyographic activity was noticed on neural stimulation. Endoscopy and barium studies showed voluntary antral contraction and contrast retention, respectively, in all patients. The mean resting and squeeze pressures were 26.25mmHg (range 16-62mmHg) and 50.25mmHg (range 16-113mmHg), respectively. St. Mark's incontinence scores varied between 7 and 12. There were no major surgical complications. Pudendal (inferior rectal) innervation of the perineally transposed antropylorus in total anorectal reconstruction is feasible and may improve outcomes in selected patients with end-stage fecal incontinence.

Perineal Colostomy With Spiral Smooth Muscle Graft for Neosphincter Reconstruction Following Abdominoperineal Resection of Very Low Rectal Cancer: Long-Term Outcome

To avoid abdominal colostomy and improve quality of life, several types of anorectal reconstruction following abdominoperineal resection have been proposed. The aim of this study was to assess functional results and the quality of life of patients with very low rectal cancer after abdominoperineal resection and neosphincter reconstruction by perineal colostomy with a colonic muscular cuff. Twenty-seven patients who had undergone neosphincter reconstruction with a perineal spiral cuff plasty after abdominoperineal resection were included in a retrospective study to evaluate long-term outcome. The functional results were analyzed using anal manometry and the continence score. The quality of life was measured with the global and disease-specific questionnaires European Organization for Research and Treatment of Cancer QLQ-C30 and C38. Median follow-up time was 105 months (range, 18-185 mo). The median Holschneider continence score of the study sample was 13 (continent), with a range of 10 (partially continent) to 16 (continent), thus demonstrating satisfactory functional results. The functional assessment was completed by neosphincter manometry which revealed a median resting vs compression pressure of 40 vs 96 cmH2O with a range of 5 to 81 cmH2O vs 49 to 364 cmH2O. The quality-of-life analyses showed an above-average score for both global health and disease-specific status. Spiral cuff colostomy with reconstruction after abdominoperineal resection of very low distal rectal cancer offers a surgical option for a selective group of patients with reasonable functional long-term results and an improved quality of life.

Spinal dysraphism with anorectal malformation: lumbosacral magnetic resonance imaging evaluation of 120 patients

Purpose We evaluated the prevalence of spinal dysraphism (SD) in patients with anorectal malformation (ARM) by magnetic resonance imaging (MRI). Methods From January 2002 to March 2009, 120 patients with ARM who underwent anorectal reconstruction were evaluated for SD with sacral plain film, spinal ultrasonography (US), and lumbosacral MRI. We adopted Krickenbeck international classification of ARM. Results Spinal dysraphism was present in 41 (34.2%) of 120 patients with ARM, 3 (13.0%) of 23 patients with perineal fistula, 7 (29.2%) of 24 patients with vestibular fistula, 4 (36.4%) of 11 patients with rectovesical fistula, 18 (40.9%) of 44 patients with rectourethral fistula, and 9 (60.0%) of 15 patients with cloacal anomaly ( P = .04). Among 41 patients having SD detected by MR, 26 patients (26/41; 63.4%) underwent detethering surgery for tethered spinal cord. The mean sacral ratio (SR) in patients who underwent detethering surgery (0.54 ± 0.19) was significantly lower than in patients who did not undergo detethering surgery (0.69 ± 0.13; P < .001). The optimal cutoff for the SR value predicting SD requiring detethering surgery was 0.605, with sensitivity of 65.4% and specificity of 77.7%. Conclusions Spinal dysraphism is common in patients with ARM, and its prevalence is higher in patients with complex ARM. Spinal anomalies can occur even with benign types of ARM and, therefore, that all patients should be screened. Magnetic resonance imaging is useful in detecting occult SD that may be missed by conventional radiologic evaluation, physical examination, and spinal US. We further recommend a lumbosacral MRI examination in those whose SR is lower than 0.6.

Funktioneller Outcome von Kindern mit Morbus Hirschsprung und Analatresie

Various outcomes following operative therapy for Hirschsprung's disease and anorectal malformations have been reported. Operative techniques for anorectal reconstruction have been modified several times in the past. Repair of anorectal -malformations have been performed through a posterior sagittal approach since the 1980s. This -allows an anatomically correct reconstruction of the anorectal canal. Abdominoperineal or sacro-abdominoperineal pull-through procedures, as the classical operative techniques, have been abandoned by most surgeons. Rectosigmoid-ectomy with colo-anal anastomosis, as described by Swenson and Bill in 1948, as well as the retro-rectal pull-through (Duhamel) and the endorectal pull-through (Soave) are still frequently used in surgery for Hirschsprung's disease. The development of the transanal endorectal pull-through with (Georgeson) or without (de la Torre) laparoscopic assistance has eliminated the necessity of laparotomy in selected cases. Despite significant progress in the understanding of the pathophysiology of and therapy for Hirschsprung's dis-ease and anorectal malformations, the functional results remain unsatisfactory. Functional problems occur already in early childhood and de-crease the quality of life significantly. Although complications resolve with time and the quality of life normalises in adolescence and adulthood, this might be mainly due to an adaptation strategy by the patients. For the future, a standardised and prospective study design is necessary to compare different procedures and to provide a basis for the further development of therapeutic strategies.