Anterior Sagittal Anorectoplasty Research Articles

Change over time in the postoperative defecation function in female patients with anovestibular fistula at a single institution: focus on the comparison of anal transposition with anterior sagittal anorectoplasty.

Anovestibular fistula (AVF) is the most common type of ARM in female patients. The present study investigated changes over time in the postoperative defecation function of female patients with AVF. Patient data were collected from 1984 to 2021. Eighty-eight female patients with AVF were enrolled. Patients' characteristics and the long-term outcome of defecation function were reviewed and analyzed retrospectively. The bowel function was evaluated according to the Japan Society of ARM Study Group evacuation score (ES). Thirty-eight patients underwent anal transposition (AT), and 8 underwent anterior sagittal anorectoplasty (ASARP). The total evacuation score (ES) in AVF patients reached "excellent" at nine years old, regardless of the operative procedure. The constipation scores with AT showed better improvement than those with ASARP, but soiling scores in the ASARP group showed better improvement than those in the AT group. The postoperative complications did not affect the postoperative bowel function in AVF patients. Most patients with AVF eventually achieved a satisfactory total ES. Given the difference in defecation score transition depending on the operative procedure or postoperative complications, it may be important to perform long-term defecation management via surgical procedures.

The treatment of congenital recto-vestibular fistula and recto-perineal fistula and effect of the megarectum on defecation.

This study aims to discuss the treatment of congenital recto-vestibular fistula and recto-perineal fistula, and the effect of the megarectum on defecation. Congenital recto-vestibular fistula or recto-perineal fistula is the most common type of anorectal malformation, and surgical methods include posterior sagittal anorectoplasty, anterior sagittal anorectoplasty, and mid-sagittal anorectoplasty, which can be performed at stage one or stage two after the ostomy. In the later stages of a recto-vestibular fistula, constipation is a common complication. Rectal dilatation is frequently associated with constipation, and the effect of rectal dilatation on defecation should be discussed for patients with congenital recto-vestibular or recto-perineal fistula who had rectal dilatation prior to surgery. Rectal dilatation may be one of the causes of constipation for congenital recto-vestibular fistula and recto-perineal fistula. The patients in this study were 67 children with congenital recto-vestibular fistula or recto-perineal fistula treated in our hospital from March 2013 to February 2017. All patients underwent an MRI of the spine and a barium enema. Six patients with myelodysplasia and sacral agenesis were excluded from this study. There were 18 patients with rectal dilatation (ages: 4-month-old to 1 year old, male: 3, female: 15). Seven of them had anterior sagittal anorectoplasty (group A), and 11 had anorectoplasty with dilated rectum resection (group B). Forty-three patients (ages: 3- to 10 months old, male: 6; female: 37) without a dilated rectum underwent anterior sagittal anorectoplasty (group C). All patients were followed up for 1 year to 5 years. Among the 50 patients who had undergone an anoplasty, 5 out of 7 patients with rectal dilatation developed post-operative constipation, and 3 of them had normal defecation after the second resection of the dilated rectum. Only two out of 43 patients without rectal dilatation developed post-operative constipation. One out of 11 patients with rectal dilatation who underwent anoplasty and resection of the dilated rectum developed post-operative constipation. Patients with congenital recto-vestibular fistula or recto-perineal fistula complicated by rectal dilatation are more susceptible to post-operative constipation. Resection of the dilated rectum at the same time can reduce the incidence rate of constipation. A barium enema should be performed pre-operatively for patients with congenital recto-vestibular fistula or recto-perineal fistula. If the dilated rectum is found, it can be resected at the same time.

Effect of megarectum on postoperative defecation of female patients with congenital rectovestibular fistula or rectoperineal fistula.

To assess the effect of megarectum on postoperative defecation of female patients with congenital rectovestibular fistula or rectoperineal fistula. From March 2013 to February 2021, 74 female patients with congenital rectovestibular fistula or rectoperineal fistula were treated. The age of patients ranged from 3 months to 1 year. Barium enema and spinal cord MRI were performed in all children. 4 patients were removed from the study because of spinal cord and sacral agenesis. Finally, 70 patients underwent one-stage anterior sagittal anorectoplasty (ASARP). Anal endoscopy and anorectal pressure measurement were performed 1 year after surgery. All patients were divided into two groups depending on the presence of megarectum (+) and (-) and observed for constipation and anal sphincter function. 16 patients (4 months to 1 year) were complicated with megarectum, and 5 patients (3 months to 9 months) were without megarectum. The incision infection was seen in 3 patients. All patients were followed up for 1 year to 5 years. Fecal soiling was seen in 2 patients and constipation in 14 patients. Among 16 patients with megarectum, soiling was seen in 1 patient and the constipation in 12 patients. Among 54 patients without megarectum, soiling was seen in 1 patient and constipation in 2 patients. There was a significant difference in the incidence of postoperative constipation between the two groups (megarectum (+) 75% vs. megarectum (-) 3.7% (P < 0.05)). However, there was no significant difference in the score of anal sphincters between the two groups (P < 0.05). And there was no significant difference in anal resting pressure (P = 0.49) and length of anal high pressure area (P = 0.76). 7 patients with constipation and megarectum acquired normal anal function after the dilated rectum was resected. Megarectum increases the possibility of difficult postoperative defecation in the patients with congenital rectovestibular fistula or rectoperineal fistula. However, constipation was not associated with ASARP postoperative effects on sphincter function. Resection of megarectum is helpful to the improvement of constipation.

Vestibular Fistula: A Prospective Follow up Study for the Management of Anorectovestibular Fistula in Neonates

Introduction: Anorectal Malformation (ARM) is one of the common congenital anomalies in the world. Incidence worldwide is 1 in 3000 to 5000 live births. Anorectal malformation is a well-recognized condition since antiquity and represents a wide spectrum of defects. Anorecto-Vestibular fistula (ARVF) is the commonest ARM in female children. Recto‑Vestibular anus is the most common Anorectal Malformation (ARM) in female patients, in which rectum opens immediately behind the hymen in the vestibule. Aim of the Study: The aim of this study was to evaluate and compare the outcome between Trans- Fistula Anorectoplasty (TFARP) and Anterior Sagittal Anorectoplasty (ASARP) in the management of Recto-Vestibular Fistula (RVF) among neonates in a tertiary care hospital .Methods: This was a prospective comparative study and was conducted in the Faculty of Pediatric Surgery of Bangladesh Shishu Hospital &amp; Institute, Dhaka, Bangladesh during the period from February 2017 to January 2021. In our study we took sixty (60) female neonates with vestibular fistula (VF). Among all neonates TFARP was done in 30 neonates and ASARP was done in 30 neonates for definitive correction of RVF. Result: In total 60 patients from both the groups completed the study. In our study we found the mean operation time in TFARP group and ASARP group was 65.97±4.63 minutes and 69.37±4.76 minutes. After operation, 60% neonates in TFARP group and 90% neonates in ASARP group developed complications. Most occurred complication was skin excoriation (20% &amp; 26.67%) in TFARP &amp; ASARP groups respectively. Wound dehiscence was noted significantly more in ASARP group. In TFARP group, 63.3% neonates had good, 33.3% neonates had fair and 3.3% neonates had poor functional score while in ASARP group, 56.7% neonates had good functional score &amp; 43.3% neonates had fair functional score. Conclusion: In conclusion, we found that TFARP may provide the best postoperative cosmetic appearance, parent’s satisfaction, ..........

Delayed vs. early enteral feeding after repair of congenital recto-vestibular fistula: The effect on perineal wound healing.

congenital Recto vestibular fistula represents the commonest type of anorectal malformation in females. The treatment of this anomaly is mainly approached either through anterior or posterior sagittal ano-rectoplasty approach. Several perioperative factors may affect the outcome. One of major postoperative complications is the occurrence of wound infection. We aimed to study the effect of delayed vs. early enteral feeding on the occurrence of perineal wound infection (PWI) after repair of congenital recto vestibular fistula. Fifty-five infants with recto-vestibular fistula were included. They were managed by single stage anterior sagittal anorectoplasty (ASARP) at an age ≥3 months. Groups A and B included infants who started oral intake on the 6th and 2nd postoperative days respectively. Group A infants were kept on peripheral parenteral nutrition (PPN) during the fasting period. Superficial wound infection occurred in three cases in group A while it developed in seven cases in group B. Deep perineal infection occurred in two and five cases in group A and group B respectively. The mean hospital stay was 8 days in group A vs. 13 days in group B when PWI developed. Delayed enteral feeding with PPN keeps the perineal wound less contaminated with stool. This promoted proper and fast healing with lower incidence of PWI. Also, PPN compensates the catabolic effects of both surgical trauma and fasting during the postoperative period and ensures maintenance of normal levels of essential nutrients that allow for proper healing.

Вибір тактики хірургічного лікування природжених аноректальних вад розвитку з ректовестибулярною норицею в дівчаток

Anorectal malformations in girls include a wide range of abnormalities, from the non-perforated anal membrane to the cloaca. The most common is rectovestibular fistula. Purpose - to improve the results of surgical treatment of congenital anorectal malformations with rectovestibular fistula in girls using a differentiated approach to the choice of treatment tactics. Materials and methods. A comprehensive examination of children was performed. Associated congenital malformations diagnosed with this type of anorectal anomaly have been diagnosed. According to the literature, a comparative analysis of different methods of treatment of this pathology was conducted, using primary anterior sagittal and posterior sagittal anorectoplasty, as well as two-stage or three-stage correction. The analysis of own results of three-stage surgical treatment at 35 girls with a rectovestibular fistula was carried out. The first stage was the formation of a colostomy. The second stage was differentiated, using anterior sagittal or posterior sagittal anorectoplasty. Results. The third was the closure of the colostomy. In patients who underwent anterior sagittal anorectoplasty, the results were good in 6 (60%) and in 4 (40%) - satisfactory, and in posterior sagittal anorectoplasty - in 14 (60.9%) good, and in 9 (39.1%) - satisfactory. There were no unsatisfactory results. Conclusions. With adequate colostomy, the results of anterior sagittal and posterior sagittal anorectoplasty in the postoperative period are not significant. The choice of tactics for the treatment of rectovestibular fistula in children should be determined by the surgeon, based on the general condition of the child, the presence of associated pathology and perfection of mastery of the method of correction. The research was carried out in accordance with the principles of the Helsinki declaration. The study protocol was approved by the Local ethics committee of the participating institution. The informed consent of the patient was obtained for conducting the studies. No conflict of interests was declared by the authors.

Rectovestibular fistula: Which surgical approach is suitable? A randomized controlled trial.

The management of a vestibular fistula is a challenge for pediatric surgeons. We compared four different operative techniques in terms of postoperative complications, continence, and cosmetic appearance. This prospective, randomized, comparative study included female children with rectovestibular fistulae who were selected from patients with Anorectal Malformations (ARMs) treated between January 2016 and July 2020. The patients were randomly divided into four groups based on the operative technique: Trans-Sphincter Anorectoplasty (TSARP), Posterior Sagittal Anorectoplasty (PSARP), Classic Anterior Sagittal Anorectoplasty (ASARP), and modified ASARP. The incidence of vestibular fistulae among all patients with ARMs was 13.4%. The total number of patients with vestibular fistula was 112, including eighty-four (75%) with rectovestibular fistulae and twenty-eight (25%) with anovestibular fistulae. Associated congenital anomalies were found in nineteen (22.6%) patients. The percentage of parents satisfied with the cosmetic appearance and continence of their children was the highest after TSARP. PSARP had the lowest incidence regarding vaginal wall injuries. TSARP is the best operative technique for handling rectovestibular fistulae and is suitable for infants and children. In the TSARP technique, the external sphincter muscle can be preserved following complete dissection of the rectum without the need for a midline skin incision. A midline skin incision is required in the modified ASARP technique.

Laparoscopic-Assisted Anorectoplasty for Rectovestibular Fistula: A Comparison Study with Anterior Sagittal Anorectoplasty.

Posterior or anterior sagittal anorectoplasty (ASARP) is the mainstream for correcting rectovestibular fistula (RVF). However, the intermediate RVF has the potential risk of wound complications when applying ASARP due to its high rectal pouch, long fistula tract, and difficulty separating the rectum and vagina. We developed laparoscopic-assisted anorectoplasty (LAARP) for surgical correction of RVF, which has acceptable preliminary outcomes. The purpose of this study is to evaluate the safety and efficacy of LAARP in comparison with ASARP for patients with RVF. Twenty-five patients with RVF who underwent LAARP between October 2017 and December 2020 were retrospectively reviewed. The outcomes were compared with 43 patients who underwent ASARP between April 2015 and August 2018. The age, weight at operation, sacral ratio, operative time, and postoperative hospital stay were evaluated. The results were assessed for complications, perineum appearance, and bowel function. The two groups were comparable in terms of demographics. The median operative time of the LAARP group was significantly longer than that of the ASARP group (113 vs. 95 minutes; p = 0.015). The mean length of the resected rectum in the LAARP group was also longer than that in the ASARP group (6.75 ± 5.07 vs. 3.31 ± 3.06 cm; p = 0.001). Compared with the LAARP group, complications in the ASARP group were more frequent (4.0 vs. 27.9%, p = 0.036). No intraoperative or postoperative wound-related complications occurred in the LAARP group. However, in the ASARP group, one patient had an intraoperative vaginal injury and four had postoperative anastomosis-related complications. The incidence of redo operation in the ASARP group was significantly higher than that in the LAARP group (p = 0.000). Cosmetic satisfaction was higher in the LAARP group (96.0 vs. 76.7%; p < 0.05). In terms of voluntary bowel movement, soiling, and constipation, the LAARP group had similar results compare with the ASARP group. The LAARP technique has shown several unique strengths in treating intermediate type RVF, including lower risks of complications, and minimal muscular injury, with a comparable bowel function.

H-type ano-bulbar urethral fistula with an ectopic perineal fistula in a male patient complicated with VACTER association

Congenital H-type fistula is a rare congenital rectourogenital anomaly and is less common in males than in females. A one-year-and-eight-month-old boy with an ectopic perineal fistula was incidentally diagnosed with H-type fistula when he underwent voiding cystourethrography for vesicoureteral reflux. Further examination revealed that the H-type fistula was an ano-bulbar urethral fistula. At two years of age, the patient underwent fistulectomy and also anterior sagittal anorectoplasty for the ectopic perineal fistula during the same surgery.

Early results of different types of anorectoplasty for anorectal malformations

Objective: To document our experience with the technique of surgical repair in anorectal malformations (ARM) and the short term anatomical and functional outcomes. Methods: This study included total 31 babies. Fourteen were perineal fistula cases with age range between 1 to 4 days. Ten patients had vestibular fistula and seven had rectourinary fistula. Primary diverting colostomy was done for vestibular and rectourinary fistula patients. On the other hand low imperforate anus with anoperineal fistula without associated major anomalies had undergone fistulectomy and simple anoplasty. Results: Simple anoplasty was done for fourteen perineal fistula cases. Anterior sagittal anorectoplasty (ASARP) was done for 10 vestibular fistulae and posterior sagittal anorectoplasty (PSARP) was done in 10 recto-urinary fistula cases. Simple anoplasty and vestibular anus scored good (5-6) in 70% to 71% while PSARP scored fair in 58% of the cases. Postoperative mucosal prolapse, anal stenosis and retraction occurred in two, six and one patient respectively. Redo surgery was done in mucosal prolapse and retraction cases. Four responded to anal dilation and the other needed redo surgery by a simple cutback technique for anal stricture. Continence was assessed in 23 patients whose follow-up periods were longer than 3 years. Twenty one patients had a good score and two had a fair score. No patients had a poor score. Conclusion: Our approach has the following advantages: (i) The operative technique is simple and easy to perform. (ii) Minimal complication rate with good cosmetic results. Mediscope 2021;8(2): 75-79

The early outcome of primary anterior sagittal approach for low anorectal malformations in female patients.

Objective:To document our experience of the primary anterior sagittal anorectoplasty (ASARP) in female patients with lower and wide fistula in term of the early post operative outcome.Methods:A retrospective descriptive study was conducted in one surgical unit of the National Institute of Child Health Karachi, from January 2010 to April 2018. The study included female patients with diagnosis of imperforate anus with wide Vestibular or Perineal fistula with minimal or no straining during defecation and no excoriation of perineum. All patients underwent primaryASARP. Data regarding the age of the patients, site of fistula, the difficulties in dissection, post operative complications, stoma and re-do ASARP needed, were documented. Wound assessment was done during hospital stay, at two weeks and then at three months after surgery. Outcome was documented in terms of complications of surgery and cosmetic appearance of perineum. Data was analyzed on SPSS version 20.Results:A total of 70 patients underwent primary surgery, 48(68.57%) females had perineal fistula while 22(31.42%) had vestibular fistula. Age ranges between three months to 276 months with median of 6±39.73 months. No major injury to the rectal or vaginal wall occurred during surgical procedure. In early post-operative period, 12(17.14%) patients had wound infection with or without various extent of disruption. A total of seven (10.11%) patients underwent stoma formation, six (8.57%) patients because of wound disruption with in a week of primary surgery and in one patient due to severe anal stenosis and retraction of anal segment within three month follow up. Median hospital stay was 5±1.52 days. In 38(54.28%) paients complete wound healing occurred with no per or post operative complications. In 25(35.71%) patients, minor complications were noted and treated accordingly and results were labelled satisfactory with acceptable perineal appearance.Conclusion:The single stage procedure can be a good choice for both vestibular and perineal fisula. In majority of cases wound heals completely with minimal or no scaring and give good cosmetic results.

Anterior Sagittal Anorectoplasty: Our Experience.

Context:Anterior sagittal anorectoplasty (ASARP) is accepted as one of the techniques for the repair of vestibular fistula (VF) and low-type anomalies, but some may have reservations.Aims:The aim of the study is to describe the technique, important features, and functional and cosmetic outcomes of ASARP for the treatment of anorectal malformation (ARM) in females.Settings and Design:A prospective study was performed from 1992 to 2017.Materials and Methods:The study included 157 pediatric patients (aged 1–15 years) with diagnosis of ARMs with VF, perineal fistula (perineal ectopic anus), and rectovaginal fistula managed by ASARP.Results:Most cases (36.94%) were 1–6 months' age group; 92.99% of patients (146) were having VF, 5.09% (8) perineal fistula, and 1.91% (3) rectovaginal fistula. Associated anomalies (37) were present in 19.75% (31) of patients. Primary ASARP was performed in 85.35% (134) of cases. The mean operative time was 105 (±15) min. Intraoperative complications were seen in 3.82% (6) of patients. Early postoperative complications were seen in 5.09% (8) of patients – wound infection (4), wound dehiscence (3), and retraction of the rectum (1). Late complications were seen in 12.73% (20) of cases. Overall, five patients developed anal stenosis, two responded to dilatation therapy, and three required anoplasty. The external appearance of the perineum after the 3rd month (postoperatively) was satisfactory in 95.54% (150); overall, 4.46% (7) of patients required the second procedure. Stooling pattern could be assessed in 80.25% (126) of patients at 3 years' age group. Only one had poor outcome with severe soiling (incontinence) and perineal excoriation that also had myelomeningocele.Conclusions:ASARP is an excellent procedure for VF as it results in optimal correction with minimal sphincteric damage, without additional complexity or difficulties. Primary ASARP is a quick and effective technique and does not require colostomy if performed after due preoperative gut preparation and by an experienced pediatric surgeon.

Isolated anorectal malformation with rectoperineal fistula in monozygotic twins

Abstract Incidence of anorectal malformation (ARM) is reportedly 1 in approximately 2500–5000 live births. While its etiology remains elusive, most evidence indicates genetic factors to be the major cause. One-third of all ARM cases are isolated, whereas the others are a part of other anomalies (syndromic). Herein, we report a case of low-level ARM with anocutaneous fistula in monozygotic twins. Male monozygotic twins (birth weight, 3036 and 2706 g, respectively) were born to a 31-year-old woman at gestational week 36. The twins’ physical examination revealed imperforated anus with anocutaneous fistula. Anterior sagittal anorectoplasty (ASARP) was performed when the twins were 2 years old. The postoperative course was uneventful, and their postoperative anal functions were satisfactory. No other complications were noted. ARM in monozygotic twins is rare. Reports on familial ARM will help clarify the pathogenesis of ARM and other congenital diseases.

Anterior sagittal anorectoplasty as a technique for the repair of female anorectal malformations: A twenty two-years-single-center experience

BackgroundAnorectal malformations (ARMs) are major congenital malformations occurring in female children in approximately 1 out of every 4000–5000 births. Posterior sagittal anorectoplasty (PSARP) was introduced for their treatment in early 1980s by Pena and Devries. However, anterior sagittal anorectoplasty (ASARP) was first introduced by Okada as a modification of the previous technique. PurposeThe aim of this study was to report our experience and the long-term follow-up results of 594 female patients with anorectal malformations treated by anterior sagittal anorectoplasty (ASARP) in a single center over 22 years. We chose this approach as the incision is smaller, with minimal cutting of the external sphincter and easier dissection of the vagina and rectum.The type of our study was retrospective study. ResultsThe study included 594 patients; 342 of them were less than 1 year old. About 526 patients had rectovestibular fistula, anterior perineal anus in 55 patients, anocutaneous fistula in 6 patients and rectovaginal fistula in 7 patients. All of these patients had been subjected to ASARP technique which had been done in one stage without proceeding colostomy in about 470 cases and in staged fashion with a protective colostomy in 124 patients. Postoperative follow up revealed that four patients (0.7%) developed anal retraction, 30 patients (5%) developed anal stricture, 20 patients (3.4%) had rectal prolapse and 40 patients (6.7%) developed anterior anal migration. Constipation was observed in 161 patients (27%) by the end of 1st postoperative year reduced to 41 patients (7%) after one year. 474 patients were assessed for continence by Kelly's continence score and 453 patients showed good result, 16 patients showed fair result and about 5 patients had poor continence outcome. ConclusionAnterior sagittal anorectoplasty is a procedure with optimal functional outcome especially at if done at an early age in one stage without preliminary colostomy.

Investigation of the feasibility and safety of single-stage anorectoplasty in neonates with anovestibular fistula.

Anovestibular fistula (AVF) is the most common type of anorectal malformation in females. Delayed anorectoplasty with fistula dilatation is commonly performed during infancy; however, we have been actively performing anorectoplasty in neonates. We report the surgical complications and postoperative defecation function associated with single-stage anorectoplasty performed in neonates. Patients who underwent surgery for AVF between 2007 and 2017 at two institutions were retrospectively studied. The operation time, amount of bleeding, time to start oral intake, perioperative complications, and Kelly's score were compared among patients who underwent surgery as neonates and those who underwent surgery as infants. Eighteen neonates and 17 infants underwent anterior sagittal anorectoplasty. The median operation time and time to start oral intake were significantly shorter in the neonatal group (72min; 3days, respectively) than in the infant group (110min, p = 0.0002; 5days, p = 0.0024, respectively). Postoperative wound disruption was significantly more frequent in the infant group. Of the ten patients each in the neonatal and infant groups, there was no significant difference in Kelly's score at age ≥ 4years. Single-stage anorectoplasty in neonates with AVF can be feasibly performed and does not impair postoperative defecation function. III.

Functional assessment of the patients with perineal and vestibular fistula treated by anterior sagittal anorectoplasty.

Background:Anterior sagittal anorectoplasty (ASARP) has been a standardised operative treatment for anorectal malformation (ARM). This retrospective study was undertaken to evaluate patients with perineal fistula (PF) and vestibular fistula (VF) treated by ASARP in our institution.Patients and Methods:Twenty patients (PF, n = 14; male, n = 8 and female, n = 6 and VF, n = 6) were evaluated. Eighteen patients underwent primary ASARP without protective colostomy. Two patients underwent colostomy because of intestinal atresia and suspected of other type ARM. The age range of operation was from 4 months to 5.0 years. Sixteen patients (PF, n = 13; male, n = 7 and female n = 6 and VF, n = 3) over 3 years of age were evaluated according to the Krickenbeck classification.Results:Operative complications occurred in one patient. Minor wound dehiscence occurred in six patients. Mucosal prolapse occurred in two patients. According to the Krickenbeck classification, amongst male patients with PF, all patients had voluntary bowel movements (VBMs) and two patients had Grade 1 soiling, while four patients had Grade 2 constipation. Amongst female patients with PF, all patients had VBM and no soiling, one patient had Grade 1 and two patients had Grade 2 constipation. In patients with VF, one patient was continent with Grade 1 soiling. One patient had Grade 2 and two patients had Grade 3 constipation.Conclusions:ASARP without colostomy carried a risk of wound dehiscence. The ASARP technique provided normal or moderate outcomes for VBM and soiling. However, in about half of patients, defecation management with laxative therapy was required to achieve a normal condition.

Anterior Sagittal Anorectoplasty with External Sphincter Preservation for the Treatment of Recto-vestibular Fistula: A New Approach.

Context:To our knowledge, there is no description of anterior sagittal anorectoplasty (ASARP) with external anal sphincter preservation and passing neorectum in the middle of muscle complex under direct vision for the treatment of recto-vestibular fistula (VF).Aim:This study evaluates a new modification combining ASARP with under vision sphincter preservation.Subjects and Methods:This prospective study was conducted on thirty female infants with VF. Procedure starts with a vertical midline incision extending from ectopic opening to posterior limit of external sphincter. Sharp dissection of the fistula is carried out. Artery forceps is passed at the center of muscle complex under vision, then neorectum is placed in the middle of the muscle complex. We introduced a new scoring system based on parental interview assessing functional outcome. Each patient was given a score between 0 and 20; good: 14–20, fair: 7–13, and poor: 0–6.Results:ASARP was performed at a mean age of 2.6 months, a mean weight of 5.2 kg, a mean operative time of 102 min, and a mean hospital stay of 3.6 days. Wound infection occurred in four cases, seven cases had perianal excoriations, six cases had anal stenosis, and only one case complained of anal displacement. Patients followed for a mean of 18.8 months. Majority of our patients (50%) had good score (mean = 16.8), normal frequency, no or mild soiling, normal anal position with no or mild stenosis. Fourteen patients had fair score (mean = 10.5). Only one had poor outcome with severe soiling and perineal excoriation.Conclusion:Our modification offers optimal correction, with minimal sphincteric damage, without additional complexity or difficulties. Scoring system is simple, practical, and truly reflects early functional and parent satisfaction after surgery.

Anorectal Malformations in Adolescent Females: A Retrospective Study.

Context:While most of the females with anorectal malformations (ARMs) present in either neonatal period or early infancy, a small percentage presents in their adolescence.Aim:The aim is to study the causes of delay in presentation, management, and postoperative outcome in these cases.Settings and Design:This is a retrospective observational study conducted in the Department of Paediatric Surgery, King George's Medical University, Lucknow.Subjects and Methods:Records of females with ARM managed in one unit of the department from 2010 to 2015 were scrutinized. Of these, record of females who primarily presented in adolescence was reviewed. Data regarding the demographics, clinicoradiological presentation, management, postoperative stay, and follow-up were analyzed. Causes for delay in presentation were looked for.Statistical Analysis Used:Statistical analysis used was not required.Results:Out of 627 cases of ARM managed over 5 years, ten girls (5.3%) presented between 12 and 18 years (average 14.4 years). Main reasons for the delay in presentation were misinformation, illiteracy, and poverty. These comprised of anovestibular fistula (n = 5), anterior ectopic anus (n = 3), perineal canal (n = 1), and rectovestibular fistula (n = 1). Three (30%) girls had no problem apart from an abnormal anal orifice. Five (50%) girls had constipation as a major additional symptom. Four cases had a normal to mildly enlarged rectum on contrast study, whereas the rectum was moderately to hugely dilated in the remaining six cases. Six cases were managed with posterior sagittal anorectoplasty while an anterior sagittal anorectoplasty was done in four. Minor wound dehiscence developed in two cases. There was no mortality. In a mean follow-up of 16 months (8–26), constipation and soiling were seen in 5 (50%) girls. The overall outcome in these girls was satisfactory.Conclusion:Presentation of females with ARM in adolescence is not uncommon in the third world. A primary pull through is possible in these girls with mild-to-moderate rectal dilatations. A diverting colostomy before pull through is always a safe option in cases with severely dilated rectum and also otherwise. Moreover, a greater awareness regarding these malformations in the general public is required.

Revision Surgery in the Management of Anorectal Malformations: Experience from a Tertiary Center of India.

Aim and Objectives:Despite the significant advancements in the management of anorectal malformations (ARMs), there are various surgical and functional complications reported. Complications are closely related with the surgical techniques adopted and the types of malformations. In this article, we present our experiences with ARM patients who required reoperation after unsuccessful previous surgeries or who had developed complications related to the previous surgical techniques.Materials and Methods:We retrospectively reviewed clinical and electronic records of all the patients with ARM who were operated for ARMs in our institute from June 2010 to May 2016. All ARM patients who needed reoperation were included in the study. These patients were previously operated outside our institute and referred to us with ongoing problems of constipation, stool impaction with overflow incontinence, perineal soiling, and difficult urination.Results:There were 31 patients (M:F = 2.1:1) of ARM, reoperated for 38 indications during the above-mentioned period. Five patients had more than one problem. Presentation included neoanal stenosis (11), complete obliteration of neoanus (2), malpositioned neoanus (2), persistent/recurrent rectourethral fistula (3), iatrogenic rectovaginal fistula (4), rectal prolapse (5), large widened neoanus with soiling (2), and urethral stricture (2), which required revision interventions. Six patients had megarectum. All patients showed improvement in their symptoms after revision surgery, but 10 (41.7%) patients required further regular bowel management program (BMP) to avoid the soiling and constipation. Fourteen (58.3%) patients stayed clean without regular BMP.Conclusion:All these complications had clear explanations and are well described in the literature. Revision surgery in such patients had fair outcome, but some sort of BMP was required. Both posterior sagittal anorectoplasty and anterior sagittal anorectoplasty are excellent techniques for revision surgery with few simple modifications.

Treatment Efficacy of Different Surgical Procedures for Postoperative Residual Rectourethral Fistula Following Anoplasty

Background/Purpose: This study summarizes the surgical treatment options and their clinical efficacy for postoperative residual rectourethral fistula following anoplasty in patients treated in our department from July 2005 to July 2012. Methods: For 38 cases of postoperative residual rectourethral fistula following anoplasty, according to differences in anal appearance and functionality, either an anterior sagittal or a posterior sagittal surgical rectourethral fistula repair procedure was performed. Results: The residual rectourethral fistula following anoplasty was an obvious tube-like structure with a length of 0.9 ± 0.4 cm. Healing after the 1-stage operation was achieved in 37 cases. Among these cases, 35 were followed up and showed no urethral stricture and no diverticulum. The clinical score for anal function was excellent in 31 cases and good in 4 cases, with significant differences compared with the scores before surgery (P &amp;lt; 0.05). The respective operative times for the 2 surgical procedures were 74.6 ± 10.1 minutes and 105.6 ± 14.6 minutes (P &amp;lt; 0.05). Conclusions: The appropriate choice of surgical procedure was dependent on the patients' anal appearance and functionality. Posterior sagittal anorectoplasty was suitable in cases with a severely disordered perineal appearance, and it was a relatively difficult operation. In contrast, anterior sagittal anorectoplasty was best applied in patients with minor alteration in perineal appearance, and it had a clear surgical field and was easy to perform. In this study, the repair of cases of residual rectourethral fistula following anoplasty using anterior sagittal or posterior sagittal anorectoplasty showed high success rates, and anal function was significantly improved.