High Anorectal Malformation Research Articles

Evaluation of Anal Position Indexes from Anal Dimple and Neoanus at Sphincter Muscle Complex in Children with High Anorectal Malformations in Kano, Nigeria.

Anorectal malformations (ARMs) comprise a spectrum of congenital anomalies that continue to present a challenge to patients, caregivers and paediatric surgeons. The main objective of this study was to determine the anal position index (API) from anal dimple and neoanus at the sphincter muscle complex in children with high ARM. Using a cross-sectional study design, the API was assessed from anal dimple and neoanus at the sphincter muscle complex in children with high ARM. All eligible children with high ARM who presented to AKTH during the study period were recruited into the study. Forty eligible patients with an age range of 8 months to 108 months were recruited. Twenty-five were males (62.5%) with a male: female ratio of 1.7:1. The mean pre-operative API using anal dimple was 0.47 ± 0.05, while that of the post-operative API using neoanus was 0.53 ± 0.04. There was a statistically significant difference between the two indices (t = -11.8, P < 0.01). There was also a statistically significant difference amongst male and female indices P < 0.05, but there were no significant differences between different age groups. This study has shown that there was a statistically significant difference between the pre-operative API and post-operative API; thus, the position of the anal dimple does not significantly predict the central position of the sphincter muscle complex.

An Emergency and Challenging Life-Saving Surgery in a Newborn with Imperforate Anus in a Remote Village in South Sudan – A Case Report

Anorectal malformation, a congenital defect is usually detected at birth and managed by a multispeciality team in a tertiary care hospital. We present a case of a five day old neonate, born in a remote village in South Sudan, who presented in a critical condition to our field hospital and was managed with basic resources. A 5 day old neonate was detected with imperforate anus and presented to our hospital on day 5 with abdominal distension, severe dehydration, tachycardia and tachypnoea. Radiographic investigations revealed findings suggestive of a high ano-rectal malformation. The neonate underwent an emergency exploratory Laparotomy with diversion double barrel Colostomy in a set up catering for adult combatants. The neonate gradually improved before developing burst abdomen managed with emergency wound closure. The neonate gradually accepted breast feeds and was discharged for subsequent need for definitive surgery. This was a challenging surgery with respect to the resources available at a field hospital catering to adult combatants.

Abdominoperineal posterior sagittal anorectoplasty without protective colostomy in high arm pouch colon surgery

Background: In high anorectal malformations (ARM), surgical management includes initial colostomy at neonatal period followed by abdominoperineal posterior sagittal anorectoplasty (PSARP) without a protective colostomy. Aims and Objectives: The aims of this study were as follows: (i) To evaluate whether 2 stage PSARP gives better outcome for high ARM than three stage and (ii) to assess overall stay duration, cost incurred, and complications associated with two stage PSARP. Materials and Methods: A total 30 patients were studied. Fifteen patients with classical abdominoperineal PSARP with protective colostomy (three stages) constituting Group A studied retrospectively and 15 patients were studied in Group B who underwent neonatal colostomy followed by abdominoperineal PSARP without protective colostomy (Two stages). Comparative study was done between the two groups for a better choice of procedure in high ARM patients. Results: In Group A, blood transfusion required was more than Group B. Mean expense incurred in Group A was more than Group B. Complications in Group A occur in eight patients, whereas in Group B, complications occurred in six patients. Conclusion: Stages of high ARM and pouch colon are better alternative to three stages repair in all aspect.

Perawatan Stoma pada Bayi dengan Malformasi Anorektal Letak Tinggi tanpa Fistula di Ruang Neonatal Intensive Care Unit : Studi Kasus

Anorectal malformation without fistula is a congenital disorder that requires a colostomy. Stoma care is very important to prevent infection in neonates, with good care it is hoped that there will be no damage to the integrity of the skin area around the stoma.&#x0D; This study was to report changes in skin color around the stoma in infants with high anorectal malformations without fistulas in the Neonatal Intensive Care Unit (NICU) after stoma treatment.&#x0D; Using a case study design by describing the nursing care given to baby S with a gestational age of 38 weeks in a level III A NICU room at Dr. Wahidin Sudirohusodo Hospital Makassar. Data were collected through observation and documentation of stoma care twice at an 8-day interval. Presentation of data using narrative in explaining the results obtained from case studies&#x0D; After the stoma treatment, the skin color appears reddish, and there is no necrotic. Interventions performed on infants with colostomy are stoma care to prevent damage to skin integrity. On were the first observation before the stoma treatment, the skin color around the stoma was brownish and there was necrotic then, after the stoma treatment, the skin color appeared reddish, there was no necrotic.&#x0D; In conclusion, changes in the skin color of the area around the stoma improved after treatment, the patient's stoma appeared to change from brown and there was necrotic to reddish color and no necrotic.&#x0D;

Tips and Tricks-3 Use Cases of Interdisciplinary Knowledge Transfer in Minimally Invasive Pediatric Surgery.

In the pediatric surgical environment, we can enrich our knowledge and improve our skills through interdisciplinary knowledge transfer in exchange with other surgical or even non-surgical disciplines. To demonstrate this, we present in this article three patient cases of method transfer enabling new techniques in minimally invasive pediatric surgery. 1. The somewhat modified application of the AeroStat rigid tip laparoscopic cholangiography catheter during the single-step laparoscopic cholecystectomy facilitates the safe intraoperative cholangiography with common bile duct flushing. 2. A magnetic rod is used during laparoscopic enterotomy to locate and retrieve ingested magnets. 3. Using a patient-specific MRI 3D model representing a syndromic high anorectal malformation improves surgical planning and parental education.

A rare presentation of OEIS variant with a recto-bladder neck fistula: A case report and literature review.

IntroductionOmphalocele, bladder extrophy, imperforate anus and spinal defect (known as OEIS) is a very rare congenital anomaly with an unknown etiology. In this report we describe a case of an OEIS variant associated with a wide pubic diastasis, bladder extrophy with a recto-bladder neck fistula and a high ano-rectal malformation. This work has been reported in line with the SCARE 2020 criteria.Presentation of the caseA 30-year-old mother delivered a male baby at 39 weeks through a normal vaginal delivery. Examination revealed multiple congenital anomalies in the form of an Omphalocele, extrophied bladder, imperforate anus, ambiguous genitalia and a large pelvic diastasis. Fecal matter was noted at the most inferior point of the extrophied bladder, raising the suspicion of a recto- vesical fistula.An exploratory laparotomy showed a fistula between the rectum and the neck of the extrophied bladder. A sigmoid colostomy was carried out in addition to a mucous fistula. The fascial defect of the Omphalocele was approximated to the upper border of the extrophied bladder.At the age of 2 years, the baby underwent a bladder extrophy repair, a posterior sagittal anorectoplasty and bilateral osteotomies.DiscussionOEIS complex has been reported to occur with a wide variety of associated anomalies, and this necessitates a thorough investigation in order to formulate an appropriate treatment plan. A prenatal diagnosis of OEIS complex can be made by ultrasound stressing the importance of antenatal follow up and a multidisciplinary approach in management.ConclusionWe described a rare variant of an OEIS complex and management of such anomalies requires a multidisciplinary input.

Laparoscopic-assisted anorectal pull-through vs. posterior sagittal anorectoplasty for treating high anorectal malformations: a single-center experience

Background/purposeSurgical management of high-type anorectal malformations (ARM) has evolved over the years with the widespread of the laparoscopic approach over the last two decades. This study aims to compare the outcome of patients with high anorectal malformation (ARM) managed with laparoscopic-assisted anorectal pull-through (LAARP) vs. the open posterior sagittal anorectoplasty (PSARP) at a single Institution.MethodsA retrospective chart review of pediatric patients, who were managed for high-type ARM at our institution, was performed for the period 2000–2015. Nine were excluded because of a lack of important data. Demographic data, surgical approach, associated anomalies, and complications were collected. Functional outcome was measured using the modified clinical scoring for the defecation function of the Japanese study group of anorectal anomalies. Comparison between groups was done using the T test for continuous variables and the Fisher-exact test for proportions. P < 0.05 is considered statistically significant.ResultsThere were 82 patients with high type imperforate anus (59 males and 23 females) 73% had laparoscopy vs. 27% open. Type of fistulae were rectourethral (36), rectovesical (12), no fistula (19), and (15) cloaca anomalies. Patients underwent surgery at a mean age 8.4 (laparoscopy) vs. 10.1 (open) months (P value = 0.14). There was no difference between the two groups regarding weight at the surgery or associated anomalies, except for VACTRAL and genitourinary malformations which were more among the laparoscopic group (8 vs. 1).There was no statistical significance for all elements of defecation function score: sensation, constipation, and soiling (P values 0.17, 0.6, 0.07, respectively). There was no difference between the two groups regarding rectal prolapse (P = 0.06), whereas rectal stenosis is more in PSARP compared to LAARP (P = 0.03). The hospital stay was significantly shorter in LAARP 7.1 vs. 9.4 (P = 0.006).ConclusionsThe defecation function and complication rate for both laparoscopic and open groups were almost similar. This may justify the preference of the laparoscopic approach over the open one, given its minimally invasive nature.

An extremely rare case of diphallia with high anorectal malformation with perineal lipoma

Diphallia is a very rare congenital anomalies occurs 1: 5-6 Million live birth. Associated anomalies like imperforate anus, vertebral deformities, double bladder, exstrophy of the cloacae, and duplication of the recto sigmoid may occurs in association with this. Amongst all anorectal malformations is a common congenital anomaly that can occur in association with diphallia. Here we are presenting a neonate with double functional penis, partial scrotal dysraphism, high anorectal malformations, presence of spina bifida occulta and a perineal lipoma successfully managed by us at our center

An extremely rare case of diphallia with high anorectal malformation with perineal lipoma

Diphallia is a very rare congenital anomalies occurs 1: 5-6 Million live birth. Associated anomalies like imperforate anus, vertebral deformities, double bladder, exstrophy of the cloacae, and duplication of the recto sigmoid may occurs in association with this. Amongst all anorectal malformations is a common congenital anomaly that can occur in association with diphallia. Here we are presenting a neonate with double functional penis, partial scrotal dysraphism, high anorectal malformations, presence of spina bifida occulta and a perineal lipoma successfully managed by us at our center

Lumbosacral Nevus Simplex in a Newborn Girl with an Asymmetrical Y-Shaped Gluteal Cleft

Lumbosacral Nevus Simplex in a Newborn Girl with an Asymmetrical Y-Shaped Gluteal Cleft

Congenital pouch colon with colonic atresia- An unusual embryological association: A case report

Background: Congenital pouch colon (CPC) is a rare variant of high anorectal malformation. More and more varied associations of CPC with other entities are being added to the literature. Case presentation: A 1-day-old male baby presented to the emergency room with marked abdominal distension and absent anal opening. On exploration, the baby was found to have CPC (Type 2) with colonic atresia. This association has not been reported in English literature. Conclusion: This is a report of a case of type 2 CPC with colonic atresia. To the best of our knowledge, such an association has not been reported so far. The final embryological outcome is dictated both by the topography and timing of vascular insult.

Anorectal malformations: Early outcome analysis in a tertiary care center in India

Background: Delayed diagnosis, referral, and presence of associated anomalies may influence the outcome of Anorectal malformations (ARM). The aim of this study was to analyze the early outcomes (1 month postoperatively) of ARM presenting in the neonatal period. Methods: A prospective study was carried out in our tertiary care teaching institute from December 2018 to March 2020. All neonates admitted in the NICU with ARM were studied. Results: There were 315 neonates; out of these, 236 (74.92%) were male and 79 (25.07%) were female. High ARM (HARM) was present in 265 (84.13%) and low ARM (LARM) in 50 (15.87%). Associated congenital anomalies were noted in 121 (38.41%). Major associated anomalies consisted of gastrointestinal (GIT) (41.32%), oesophageal (31.4%), and genitourinary (GU) (19.83%). Out of 306 procedures for ARM, 196 (64.05%) neonates underwent left transverse colostomy (LTC). The most frequent postoperative complications were thrombocytopenia (115) followed by sepsis (98). Colostomy prolapse was uncommon (2). The overall mortality was 87/315 (27.61%) neonates - 82/265 (30.94%) in HARM and 5/50 (10%) in LARM. Neonatal mortality was significantly high with birth weight &lt;2500gm 55/153 (35.94%; p value= 0.0001), associated malformations 82 (67.76%, p value= 0.003); and delayed presentation 40/87 (45%), and with primary perforation 5/6 (83.33%). Conclusions: Higher mortality was associated with low birth weight, double/ triple atresia, neonatal GIT perforation, sepsis on admission, and those with oesophageal and cardiac anomalies. More than 1/3rd (38.41%) patients had associated anomalies; thus, a detailed systematic evaluation of all subtypes is paramount.

Role of urodynamics in male patients of high-anorectal malformations: a prospective study.

Association of spinal or vertebral anomalies and the iatrogenic denervation during surgical correction of anorectal malformation patients especially in boys can lead to neurogenic bladder inthese subset of patients. The paucity of literature with regard to urodynamic studies focusing exclusively in male children with high-anorectal malformations (HARM) lead us to analyze the urodynamic changes. The objective was to study urodynamic profile in male patients who have undergone surgery for anorectal malformation. Male high-anorectal malformation patients who had completed all the stages of repair were prospective studied. Following the basic work up, all patients based on the urodynamics were categorized into 2 groups as safe or unsafe bladders. Unsafe bladder was defined as detrusor pressure > 40cm (high detrusor pressure) or pressure variability of 15cm of water (detrusor overactivity) or significant post-void residue. MRI was limited to patients with only abnormal urodynamics to rule out spinal causes of neurogenic bladder and due to financial constraints, it could not be offered to all patients. 41 HARM meet the exclusion criteria. All patients were asymptomatic with none having history of urinary tract infections. Ultrasound showed bladder wall thickening in 31.7% patients. UDS revealed reduction in bladder capacity and compliance was noted in 31.7% and 30% patients, respectively. Elevated detrusor pressures (> 40cm of water) were noted in 10% (4/41), detrusor overactivity with concomitant elevated detrusor pressures in 19.5% (8/41) and normal UDS in 70% (29/41). 13 patients (31.7%) had abnormal cystometric parameters with 12(30%) having unsafe bladders. MRI confirmed sacral agenesis in 1 patient with unsafe bladder. Urodynamics can demonstrate occult neurovesical dysfunction in patients with HARM. This would help in early renal protective therapy and prevent the burden of long-term sequelae of neurovesical dysfunction in HARM patients.

Evaluation of Complications of Colostomy in Children

Background and Aims This study aimed to evaluate the complications of colostomy and its management in children at tertiary care centre.Methods This descriptive observational study was conducted over a period of four years from February 2017 to January 2021. All the children below five years of age who underwent colostomy were included in the study. The demographic and clinical data on age at colostomy procedure sex clinical details indication for colostomy site type of colostomy complications of colostomy procedure morbidity and mortality due to the colostomy procedure were collected and analyzed.Results During our study period 38 children underwent colostomy procedure who had fulfilled our inclusion criteria. Among 38 children 23 60.5 children were of High Anorectal Malformations and 15 39.5 children were of Hirschsprungrsquos disease. Children who had anorectal malformation were younger and underwent colostomy in neonatal period mean 3 days plusmn 2.41 compared to those who had Hirschsprungrsquos disease who underwent colostomy procedure between one month to five years mean 6.8 months plusmn 3.55. There were 26 60.4 male and 12 31.6 female children with male to female ratio of 2.21. Complications related to colostomy procedure were seen in 28 73.7 children. Early complications like wound infection superficial wound dehiscence stoma necrosis and bleeding stoma were seen in 13 34.2 children whereas late complications like Peristomal skin excoriation Colostomy retraction Colostomy stenosis Colostomy prolapse Para colostomy hernia were seen in 15 39.5 children. Majority of complications 17 44.7 were seen in end colostomy made in Hirschsprungrsquos disease children. Systemic complications like sepsis pneumonitis was seen in early post-operative period in 8 21.1 children among which two 5.3 children succumbed due to severe sepsis and respiratory failure.Conclusions Although colostomy complications are common in children majority of the colostomy complications are prevented or minimized by good surgical technique education of parents on colostomy care and hygiene.

Impact of "Lateralizing" the Sigmoid Colostomy on Port Ergonomics in Laparoscopic Anorectoplasty for High Anorectal Malformations.

The high-type anorectal malformations (ARM) are conventionally managed by an initial left iliac fossa sigmoid colostomy, followed by laparoscopic anorectoplasty (LARP). Such a stoma occupies left half of the infraumbilical region and hinders the LARP ergonomics, leading to the surgeon's discomfort. We studied the outcome and impact of "lateralizing" (shifting laterally in the abdominal wall) the colostomy on port ergonomics. This prospective study was conducted in the pediatric surgery unit of a medical college in central India between March 2014 and June 2017 in two parts. In the first part of the study, neonates with high ARM were block randomized in two groups: conventional colostomy (CC) in left iliac fossa and lateral colostomy (LC, laterally placed abdominal colostomy). Outcomes of colostomy were compared among these two groups. In the second part of the study, 40 consecutive infants from both types of colostomy groups underwent ergonomic comparison and assessment of the surgeon's discomfort during LARP (CC-LARP and LC-LARP). Standard statistical tests were used for comparison. In the first part of the study, 203 ARM cases were included in this study; 100 underwent CC and 103 underwent LC. Colostomy prolapse, excoriation, reversed stoma, and short distal limb were significantly higher in the CC group. In the second part of the study, the LC-LARP group showed many significant advantages over the CC-LARP group, including less peri-stomal adhesions, better vision, shorter operative time, and better ergonomics (better manipulation, elevation, and azimuth angles). The LC-LARP also significantly reduced the surgeon's discomfort. Lateralization of high-sigmoid colostomy should be preferred over left iliac fossa sigmoid colostomy for ARM, as it improves the port ergonomics and reduces the surgeon's discomfort for second stage LARP.

Frequency of congenital cardiac anomalies in patients with anorectal malformations.

Objectives: To determine the frequency of congenital cardiac anomalies in patients with anorectal malformations. Study Design: Retrospective study. Setting: Department of Pediatric Surgery, Khyber Teaching Hospital, Peshawar. Period: Jan 2018 to June 2018. Material &amp; Methods: All patients from 0 to 30 days of life both males and females (Inclusion criteria) with diagnosed anorectal malformation on clinical and radiological assessment, underwent cardiovascular work up to identify any cardiovascular disease. Patients with intersex disorders and those operated elsewhere were excluded. Mean and standard deviation were calculated for age. Frequency and percentage were calculated for gender, type of anorectal malformation, genital ambiguity, previous surgical intervention and congenital cardiac anomalies. Data was stratified for age, gender, lesion level, genital ambiguity and previous surgery to see the effect modification. Results: Out of 90 patients with anorectal malformation, there were 49 (54%) males and 41 (46%) females (M: F;1:1.19). with mean age of 7.65 ± 2.43 days. There were 39 (43.34%) patients with low anorectal malformation and 51 (56.67%) patients with high anorectal malformation. Genital ambiguity and previous surgical intervention was present in 8 (8.89%) and 11 (12.23%) patients, respectively. Congenital Cardiac Anomalies were diagnosed in 16 (17.78%) patients with anorectal malformation. Congenital Cardiac Anomalies were mostly seen in age group 1-10 days (21.95%), male children (22.45%) and high anorectal malformation (23. 52%). Conclusion: The frequency of congenital cardiac anomalies in patients with anorectal malformations was found lower than local figures. The majority of congenital cardiac anomalies associated with high anorectal malformation and male gender.

Актуальні проблеми класифікації аноректальних вад розвитку в дітей у сучасних умовах (огляд літератури)

Given the diversity of anatomical and functional manifestations of congenital anorectal malformations, the most relevant remains development of classification of this pathology, for the same understanding by doctors of the manifestations of this defect and developing optimal common criteria for treatment tactics and strategies. The paper presents historical and current information on the classification of anorectal malformations in children. The main contradictory issues of the existing classifications are identified. The relevance of the use of Krickenbeck classification in the treatment of these defects is highlighted. Under the influence of different colorectal schools, historically, different educational and methodological approaches to the treatment of anorectal malformations. The first International Congress of Pediatric Surgeons was held in Melbourne, Australia, in 1970. The Melbourne meeting established an international classification of anorectal malformations. It was based on the development of defects at the stages of embryogenesis and their division by sex. Also, they are divided into: low, intermediate and high anorectal malformations. The second World Meeting of Pediatric Surgeons was held in Wingspread, Wisconsin, USA, in 1984, when F. D. Stephens and E. Smith, with a group of experts from around the world, proposed a detailed PAHR classification. The advantage of the Wingspread classification was that it could be used to predict the most optimal surgical treatment for various variants of anorectal defects. The third international conference on the development of standards for the treatment of congenital anorectal malformations took place in Krickenbeck, Germany, in 2005. This conference radically changed the latter classification, removing the terms «low», «intermediate» and «high» and the differences between female and male anomalies. The assessment depended on the presence and type of fistula. The reason for adopting such a classification was the great difficulty in comparing the results of different operations according to the old Wingspread classification. The peculiarity of this classification is the great contribution of colleagues from the Indian and Asian subcontinents to the surgical treatment of several anomalies, in particular: Pouch colon, which are rare in other countries. Today, pediatric surgeons in Ukraine generally do not use the Krickenbeck classification, despite the fact that it is generally accepted in most countries. This leads to the application of different approaches to the surgical treatment of congenital anorectal malformations, which emphasizes the relevance of further study of this issue. The informed consent of the patient was obtained for conducting the studies. Key words: congenital anorectal malformation, classification, children.

Anorectal Malformations: the Brooke Ileostomy Technique Moves to the Colon

Colostomy is considered by most authors the first step of treatment for neonates affected by high or intermediate anorectal malformations (ARMs). However, for this subset of patients, the debate between total diverting colostomy (TDC) and loop colostomy (LC) is still ongoing among the paediatric surgeons community. The aim of this paper is to present our experience consisting in applying the Brooke technique, until now used only for ileostomy, in order to perform a functionally diverting loop colostomy (FDLC) in patients with high or intermediate ARMs. At our institution, from January 2014 to December 2018, 12 patients (6 males and 6 females) with high or intermediate ARMs underwent colostomy according to the Brooke ileostomy technique. The only complication observed was mild proximal stoma prolapse in 1 patient. Creation and closure of the stomas were easy, and the final cosmetic result was very satisfying in all patients. We believe that this is a promising technique since it might overcome the drawbacks of a TDC as it is less invasive, easier, and quicker to perform. Furthermore, it guarantees final better cosmetic results, albeit functioning as a TDC.

Transperineal Intracath Meconiolysis and Evacuation Technique of "Distended" Bowel Evacuation for One-Stage Laparoscopic Anorectoplasty for High Anorectal Malformations in Males.

Introduction: One-stage anorectoplasty provides maximum potential for "normal" defecation reflexes right at birth and avoids complications and problems of colostomy. One-stage laparoscopic anorectoplasty (OSLARP) for rectourinary fistula (RUF) is restricted by distended bowel obscuring the working space for laparoscopy. This study describes transperineal intracath meconiolysis and evacuation (TIME) technique for OSLARP in the treatment of RUF in neonates. Materials and Technique: High male anorectal malformation (ARM) admitted from January 2016 to March 2019 were included in the study. Diagnosis of level of ARM was made on the basis of invertogram. Patient presenting with lethal comorbidities were excluded who underwent colostomy. The technique involved placement of a 16G intracath in the perineum through the site of future neo-anus, which was identified using muscle stimulator. Meconiolysis and evacuation was done using warm saline and 2% N-acetyl. The creation of enough abdominal space was achieved after evacuation and two working instruments were placed in paraumbilical positions. The laparoscopic dissection and division of fistula was done as followed in standard laparoscopic anorectoplasty. Results: Seventeen patients were selected for TIME technique but on laparoscopy 2 patients had severe necrotizing enterocolitis hence they underwent laparoscopy-assisted high sigmoid colostomy. Fifteen patients underwent OSLARP successfully. Mean weight was 2.5 ± 0.4 kg, mean gestational age was 36 ± 5 weeks, and mean age of presentation was 3.5 ± 1 days after birth. The TIME technique was successful decompressing bowel in all the patients. Out of 15 patients of OSLARP, 14 had rectoprostatic urethral fistula and 1 had rectovesical fistula. Mean total operative duration of OSLARP was 46 ± 15 minutes. Patients who could be followed for 3 years had good results in terms of continence and bowel movements. Discussion: TIME technique is a very simple and effective way to overcome the problem of associated colonic distention in neonatal one-stage laparoscopic anoplasty.

OPIOID FREE ANESTHESIA IN A PRE-TERM NEONATE: A CASE REPORT

Opioids play a major role in the perioperative management of pain in adults and children. Though there is significant morbidity and mortality associated with overdosage of opioids, they remain the most common means of providing analgesia in the perioperative period. We report the case of a preterm neonate born with low birth weight who underwent high sigmoid loop colostomy for high anorectal malformation using opioid-free general anesthesia with supplementation with caudal block. Successful uncomplicated extubation of preterm baby was achieved with good spontaneous efforts. Opioid free general anesthesia can prevent respiratory depression and the need for postoperative mechanical ventilation even when given to preterm neonates.