Management Of Anorectal Malformations Research Articles

Congenital Anorectal Malformations: Anything New?

Management of anorectal malformations, especially that of proximal and more severe forms have developed significantly in the last 25 years. Echography and magnetic resonance imaging have improved the diagnostic accuracy, especially in terms of associated anomalies that are the main cause of fatalities among patients with anorectal malformations. Animal models, novel molecular biological techniques and knock-out gene models have widened our knowledge on aetiology and pathogenesis of these anomalies. From early 1980s, the posterior sagittal anorectoplasty originally designed by deVries and Pena has systematized the surgical management of anorectal anomalies leading to improved functional outcomes. Surgical mini-invasive techniques are increasingly applied to the management of these anomalies, although their role is as yet not clearly established. Long-term functional follow data are also available today indicating a reasonable favourable faecal and urinary control in the majority of patients with anorectal malformations. For the patients with less favourable functional outcome there are bowel and bladder management options that provide sufficient social continence.

Reoperations in anorectal malformations

Aim of Study Significant advances have occurred in the management of anorectal malformations, yet many patients still have technical, frequently catastrophic, operative complications that are potentially avoidable. We chose to analyze our experience in patients who have previously undergone a repair which was unsuccessful and required a reoperation, to detect the technical problems that led to complications and to try to establish a set of recommendations to avoid them. Methods From a series of 1806 cases of anorectal malformations, 212 were reoperated on after a failed procedure done at another institution. The operative reports of the original procedure were analyzed, as well as our own operative findings, in an attempt to understand the causes of the complications. Results We found 303 indications for reoperation, with many patients reoperated on for more than 1 problem. Complications requiring reoperation included stricture or acquired atresia of the rectum (87 patients), mislocated rectum (76), recurrent, persistent, or acquired fistula from the rectum to a neighboring urogenital structure, or to the perineal skin (67), persistent urogenital sinus in cases of cloacas (23), rectal prolapse (21), stricture or acquired atresia of the vagina (16), stricture or acquired atresia of the urethra (8), and persistent cloaca (4). The analysis of the original operative report and/or our operative findings indicated that the most common causes of these complications were ( a) insufficient rectal mobilization owing to a dissection performed in a wrong plane, or ( b) in the presence of or inadequate colostomy located too distally, ( c) a tense anastomosis owing to inadequate mobilization, ( d) rectal devascularization caused by rectal wall damage, ( e) an error in diagnosis because of lack of a distal colostogram, ( f) incomplete separation of the rectum from the genitourinary tract, ( g) failed attempts to repair a cloaca with a common channel longer than 3 cm, or those with a very high rectum. Conclusions The complications we observed usually had a clear explanation. They can be considered preventable as adherence to specific principles in technique avoids them. Key technical maneuvers are discussed to prevent these complications.

Management of anorectal malformation in children: A 10 year experience in Sokoto, Nigeria

Management of anorectal malformation in children: A 10 year experience in Sokoto, Nigeria

Management of anorectal malformations in Varanasi, India: a long-term review of single and three stage procedures

To compare the results of the staged procedure (Group A) with the primary single stage posterior sagittal anorectoplasty (PSARP) procedure (Group B) for high and intermediate anorectal anomalies. Four hundred ninety cases of primary single stage procedure done over a period of seven years (1996-2003) were compared with 458 out of 763 cases of staged procedure (Historical control) that underwent all three stages done from 1989 to 1996. Two hundred cases that had been in regular follow up in Group A and 254 cases in Group B who had attained three years of age were evaluated for continence by Kelly's method. The approximate cost of treatment was also calculated. Continence was good in 90 cases (45%), fair in 66 cases (33%) and poor in 44 cases (22%) in Group A while it was good in 204 cases (80% ), fair in 38 cases (15%) and poor in 12 cases (5%) in Group B. In Group A, the mortality was high as only 40% cases completed all the three stages of operation. The mortality was 4.5% in Group B. Primary PSARP is recommended as the better treatment option for intermediate and high-anorectal anomalies with superior results in terms of morbidity, mortality, continence and cost.

Outcomes from the correction of anorectal malformations

Anorectal malformations have been recognized and managed since antiquity, with surgical treatment evolving to maximize anatomic reconstruction, avoid complications, and understand mechanisms of incontinence, ultimately leading to improved quality of life for patients. This review describes recent advances in the management of anorectal malformations, including prenatal diagnosis, newborn treatment, surgical correction, and postoperative care. Surgical treatment has improved with better understanding and exposure of anatomy and appreciation of the intimate relation between rectum and urinary tract. Repair of cloacal malformations has evolved to include the total urogenital mobilization and an appreciation of the complex associated Mullerian anomalies. The importance of associated urologic, gynecologic, neurologic, and orthopedic malformations has been recognized. Addition of a bowel management program to patients' postoperative care has increased dramatically the number of children who are clean and dry. Management of anorectal malformations requires an accurate clinical diagnosis, proper newborn treatment, meticulous anatomic reconstruction, and comprehensive postoperative care with the goal of having a child who is clean and dry, with an excellent quality of life, because they either have the capacity for continence or can be kept artificially clean with a comprehensive bowel management program.

‘High’ anorectal malformation in boys: Need for clarity of definition and management

Posterior sagittal anorectoplasty is purported to be the approach of choice for the treatment of both intermediate and high variety of anorectal malformations. The authors describe their devastating experiences with 2 cases of high variety of anorectal malformations in which defects were repaired thorough the posterior sagittal approach. In the first case, because of the high level of the rectal pouch, complete urethrovesical disconnection was done along with inadvertent mobilization and pull-through of urinary bladder. The patient subsequently required major reconstructive procedures. In another case, the bladder was partially mobilized before the mistake was realized; the high-lying rectum was later identified, and a pull-through was performed without any ill consequences. The authors infer that only the patients with rectal pouches ending caudal to the third sacral vertebra should have their definitive surgery performed through posterior sagittal approach. They suggest that PS3 line should be the watershed in management of anorectal malformation in boys. J Pediatr Surg 37:1637-1639. Copyright 2002, Elsevier Science (USA). All rights reserved.

Advances in the management of anorectal malformations

Background: Anorectal malformations represent a continuing challenge for the pediatric surgeon. A significant number of these children suffer from fecal incontinence, urinary incontinence, and sexual inadequacy. However, major advances in the management of these children have occurred during the last 10 years. The posterior sagittal approach has led to a better understanding of the internal anatomy of these defects, and in turn, a more rational way to manage the patients. We present here our experience with the long-term follow-up of a large series of these patients operated on by us. Methods: Clinical information from our database of patients with anorectal malformations was retrospectively reviewed. A total of 1,192 patients operated on by the authors and observed for the last 19 years are included in the database. We searched for type of malformation, associated defects, results in terms of voluntary bowel movements, soiling, constipation, and urinary control. Results: Globally, 75% of all patients have voluntary bowel movements. Half of this group still soils their underwear occasionally. Therefore, about 37.5% of all cases are considered totally continent. Constipation was the most common sequelae. Urinary incontinence was relatively common after the repair of cloacas. Male patients rarely suffered from urinary incontinence. Twenty-five percent of all cases suffered from fecal incontinence but they significantly improved their quality of life when subjected to a bowel management program. An operation called “continent appendicostomy” further improved their quality of life. Conclusion: All patients born with anorectal malformations can be kept clean of stool and dry of urine, either because they achieve bowel control or because they are subjected to a bowel management program.

Management of anorectal malformation in neonates

Anorectal malformations are one of the commonest anomalies in the new born. Major advances have been made in the last decade in operative techniques to reconstruct this abnormality. The final outcome in these babies is dependent on careful planning and operative intervention in the neonatal period. The purpose of this paper is to discuss the varied presentations of this anomaly, initial assessment and operative management with reference to our own experience.

Advances in the Management of Anorectal Malformation

Advances in the Management of Anorectal Malformation

The posterior sagittal approach: Implications in adult colorectal surgery

Posterior sagittal anorectoplasty was used for the first time in 1980 to treat anorectal malformations. This approach includes a wide exposure, through a midline posterior incision, to determine the limits of the sphincteric mechanism and to place the rectum within its limits. This approach has been used to treat children with anorectal malformations, who underwent conventional procedures that failed. The management of anorectal malformations with this approach rendered significantly better results in terms of bowel control. However, there is still a large number of patients suffering from fecal incontinence and for them a bowel management program was designed to improve their quality of life. The posterior sagittal approach was also used for the treatment of acquired conditions including tumors, post-trauma and postradiation fistulas, and other postoperative complications. A historic review of the posterior approach disclosed that Cripps, a British surgeon, published his experience with a posterior transsphincteric approach to the rectum nine years before Kraske, a German surgeon, whose name has been traditionally associated with the leadership in this approach. Kraske actually approached the rectum through a paramedian incision and never performed a real transsphincteric incision. An experimental study done in dogs by the author demonstrated that it is not harmful to divide the sphincteric mechanism. The posterior sagittal approach represents a useful alternative to treat many pelvic conditions and, therefore, it must be a part of the armamentarium of colorectal surgeons. Finally, a series of clinical experiences convinced the author that coordinated rectosigmoid motility is the most important single factor in fecal continence and, therefore, our efforts to help patients suffering from fecal incontinence must be aimed at the manipulation of bowel motility.

Management of anorectal malformations during the newborn period.

Anorectal malformations comprise a spectrum of disease. Some of these defects are minor, with an excellent functional prognosis. Others are complex and may be associated with other defects in the urinary tract that may risk the patient's life. The decision-making process for the management of a newborn with anorectal malformations is crucial; the timing and establishment of priorities are the key to success. Because the management of affected males and females differs significantly, they are discussed separately.

The role of colostomy in the management of anorectal malformations: S. Wilkins and A. Pena. Pediatr Surg Internat 3:105–109, (March), 1988

The role of colostomy in the management of anorectal malformations: S. Wilkins and A. Pena. Pediatr Surg Internat 3:105–109, (March), 1988

The role of colostomy in the management of anorectal malformations

The role of the colostomy in the definitive correction of anorectal malformations is controversial with regard no only to indications for its use, but also to location and type. We reviewed the records of 272 patients with 307 colostomies and analyzed the frequency of complications related to these controversial points. There were 250 completely divided and 57 loop colostomies, constructed in either the sigmoid or transverse colon. Twenty-five colostomies were associated with complications that included retraction, stenosis, dehiscence, prolapse, infection, bowel obstruction, sepsis, and death. Twelve additional colostomies were placed in positions that impeded the definitive correction of the malformation: 9 sigmoidostomies were too distal and 3 were located in the right-upper abdominal quadrant and did not permit pull-through without tension. Colostomy prolapse and pull-through infection were statistically less likely with a completely diverting colostomy. Thirty-five patients with rectovestibular malformations were encountered in this series. Ten were referred from other institutions after attempted repair without a colostomy and all 10 had complications of infection, dehiscence, retraction, and reopening of the fistula. In contrast, there were no complications in the remaining 25, in whom the repair was preceded by a colostomy, nor after re-repair of the other 10. These findings support the need for a colostomy prior to the repair of this malformation. We recommend a carefully constructed, high, completely diverting sigmoid colostomy prior to the initial definitive repair of anorectal malformations. A right transverse colostomy is preferable preceding redo operations.

Surgical management of anorectal malformations: a unified concept

Posterior sagittal anorectoplasty (PSARP) is a new approach for the treatment of anorectal malformations. It has allowed direct exposure of the anatomy of these defects, enabling the author to describe the spectrum of this malformation. It also permits patients to be grouped on the basis of their potential for continence and the correlation of operative findings with clinical results. Traditional anatomic concepts have proved very inaccurate. The new approach allows separation of rectum from genitourinary tract without damaging important structures. The rectum is located within the limits of the striated muscle structures in a precise manner. This approach has important implications for therapy, evaluation of results, classification, and terminology. All defects can be treated with PSARP. The size of the incision will vary according to the complexity of the malformation, from minimal PSARP in low malformations to full PSARP in higher defects. In addition, approximately 10% of all cases will require a laparotomy. Colostomy is recommended in most patients except for those with low malformations. A new classification is proposed based on practical therapeutic purposes. Patients are also grouped according to their common potential for continence, which is important for the evaluation and comparison of results. The decision to create a protective colostomy is based on clinical facts in 80%–90% of cases and on invertograms and other diagnostic tests in the remaining 10%–20%.