Anterior or posterior sagittal anorectoplasty without colostomy for low-type anorectal malformation: how to get a better outcome?

doi:10.1016/j.jpedsurg.2010.02.042

Journal of Pediatric Surgery

Volume 45, Issue 7, July 2010, Pages 1505-1508

https://doi.org/10.1016/j.jpedsurg.2010.02.042 Get rights and content

Abstract

Background/Purpose

Usually, anorectal malformations (ARM) are treated in 2 or 3 stages for fear of disturbed wound healing and subsequent damage to the anal sphincter complex. The aim of this study was to assess the feasibility, safety, advantages, and follow-up of an anterior or posterior sagittal anorectoplasty in low-type ARM (rectoperineal or rectovestibular), performed without colostomy.

Materials and Methods

Prospective collection of data regarding demographics, VACTERL (Vertebral-, Anal-, Cardiac-, Tracheo-Esophageal-, Renal-, Limb malformations) screening, perioperative measurements, surgeons, and complications.

Results

In 35 consecutive children (13 boys, 22 girls), repair of a low-type ARM was performed without colostomy. There were 13 boys and 10 girls with a rectoperineal and 12 girls with a rectovestibular fistula. The median age at operation was 4 months (range, 0-73 months); 34% being performed in the newborn period. Seventeen children had one or more other congenital anomaly. Preoperatively, all patients had rectal washouts with oral and rectal neomycin, and perioperative antibiotics, either 24 h (prophylaxis) or for 2 to 5 days. An anterior or posterior sagittal anorectoplasty was performed.

Postoperatively, 9 children had no enteral feeding and total parenteral nutrition (TPN). All children had postoperative anal dilatations according to the Peña scheme. Two children (both with rectoperineal fistula) had a wound abscess; in the first child (with renal insufficiency), a colostomy was performed and in the other child a successful correction of the anoplasty was done. In 7 children (4 rectoperineal, 3 rectovestibular fistulae), the anus eventually healed after minor wound dehiscence. There was 1 anal stricture, after a median follow up of 14 months (range, 1-84 mo). After therapeutic antibiotics (2-5 days), 11% (2/18) had some degree of wound infection, versus 41% (7/17) after either no antibiotics or after prophylactic antibiotics (24 hours). Patients with TPN did not seem to profit with regard to wound healing and one patient experienced a central line related sepsis. At last follow-up, 12 children needed regular laxatives and/or enemas. Anal dilatations were well accepted above 6 months, and a trend was seen towards less need for laxatives when dilatations were continued longer.

Conclusion

Repair of a low-type ARM without colostomy, with therapeutic antibiotics, and followed by a long period of postoperative anal dilatations has low morbidity and good outcome, which does not seem to be improved with TPN.

Section snippets

Materials and methods

In this prospective study between 1999 and 2006, 35 consecutive children were operated in one stage for a low ARM. After admission, children with a rectoperineal or rectovestibular fistula were scheduled for a reconstruction at short term. In some children, anal dilatations by the parents were started to evacuate meconium while awaiting reconstruction. All children were screened for associated anomalies. Preoperatively, rectal washouts and oral and rectal neomycin were administered. Either an

Results

In the study period, 35 consecutive children (13 boys and 22 girls) were managed according to protocol. There were 23 rectoperineal (13 boys, 10 girls) and 12 rectovestibular fistulae. The median age at operation was 4 months (range 0 to 73 mo); 12 (34%) children were younger than 1 month at operation. Seventeen children had one or more other congenital anomalies of whom the VACTERL (Vertebral-, Anal-, Cardiac-, Tracheo-Esophageal-, Renal-, Limb malformations) association in 9. Although 2

Discussion

Traditionally, ARMs are reconstructed with a protective colostomy because of fear of failure of wound healing and subsequent loss of the anal sphincter complex, with the risk of impairment of future continence. The belief that a protective colostomy may prevent wound infection, is questionable. In the recent literature, more surgeons tend to do a one-staged procedure for the rectoperineal fistulas and in some developing countries even high type ARMs are treated without colostomy [6], [7], [8],

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Cited by (52)

Early postoperative feeding in single-stage repair of anorectal malformation with vestibular or perineal fistula is not associated with increased wound complications
2023, Journal of Pediatric Surgery
Citation Excerpt :
A rescue colostomy was required in 11% (7/84) of patients with a wound complication in the single-stage group. However, in the studies reviewed, infants were kept NPO for 5–7 days postoperatively, which may increase the risk of wound complications [6]. There are limitations to this retrospective review study.
The objective of this study is to assess the postoperative outcomes of single-stage repair of anorectal malformations with vestibular (VF) or perineal fistula (PF) and early initiation of postoperative feeding.
A retrospective review of patients undergoing single-stage repair of isolated low anorectal malformations (VF and PF) from 2017 to 2020 was conducted. All patients underwent an anterior anoplasty with complete mobilization of the rectal fistula, or posterior sagittal anorectoplasty (PSARP), without protective colostomy. The variables examined include age, timing of postoperative feeding initiation, length of stay (LOS), and complications.
Nineteen patients with VF or PF underwent a single-stage repair. 12/19 (63%) patients were female. All 7 males and 9/12 females had a PF. The range of age at surgery was 2 days to 3 years with median age of 92 days [IQR 1,3: 9,193]. The median postoperative day for initiation of feeds was day 0 [IQR 1,3: 0,1] and median LOS was 1 day [IQR 1,3: 1,4.5]. 18/19 (95%) patients were evaluated in follow-up and there were no wound infections, wound dehiscences, or recurrent fistulas. Within 90 days postoperatively, no patients were seen in the emergency department for postoperative issues. Within 6 months, 2/19 (11%) patients required an unplanned return to the operating room for anal dilation.
In single-stage repair of isolated low anorectal malformations, VF and PF, early initiation of postoperative feeding is safe, results in a short length of stay, and does not lead to increased wound complications. Early enteral feeding eliminates the need for parenteral nutrition and central venous access, and their associated complications.
Level IV
Single-stage procedures for anorectal malformations: A systematic review and meta-analysis
2022, Journal of Pediatric Surgery
The purpose of this study is to describe all published studies of single-stage procedures for anorectal malformations and to perform a meta-analysis of studies that compared single-stage to staged procedures.
Searches were conducted in Pubmed, Medline, Embase and CENTRAL. Meta-analysis was performed in RevMan and expressed as forest plots with odds ratios (OR) and 95% confidence intervals (CI).
Thirty-eight studies were included in the narrative synthesis. Nine studies were included in the meta-analysis, representing 537 patients. The majority (70%) of patients included in this meta-analysis had either perineal or vestibular fistulas. Surgical site infection (SSI) was defined as any reported infection involving the neoanus (both superficial infection and dehiscence) and occurred in 51 of the 291 patients who underwent single-stage procedures, and 26 of the 244 patients who underwent staged procedure. Meta-analysis showed a 2.2 times higher risk of surgical site infection (SSI) amongst patients who undergo single-stage procedures (OR 2.22, 95% CI 1.26, 3.92). Six of the 293 patients (2%) who underwent single-stage procedures required a rescue ostomy for wound dehiscence. In LMIC the risk of wound dehiscence was three-fold higher in single-stage (36/202) compared to staged procedures (12/126) (OR 3.07, 95% CI 1.42, 6.63). In HIC there was no evidence of an increased risk of wound dehiscence in patients who underwent a single-stage (15/91) compared to a staged procedure (14/118) (OR 1.51, 95% CI 0.65, 3.51). There is no evidence of a difference between single-stage versus staged procedures with regards to functional outcomes including voluntary bowel movements (79/90 versus 111/128), soiling (24/165 versus 20/203) or constipation (27/90 versus 36/128).
This systematic review provides further evidence that single-stage procedures for selected patients with anorectal malformations are safe. Whilst there is evidence of an increased risk of SSI, this did not translate to a significant difference in long-term functional outcomes.
Level II
Anorectal anomalies in the female: Highlights on surgical management
2021, Journal of Pediatric Surgery
Citation Excerpt :
In this report, we tried to share our surgical experience with more than a hundred cases of sagittal anorectoplasty in girls with ARA. While referring to similar reports in the literature [4,5,11,19–24], we tried to provide deep analysis for the main current controversial issues and to provide reasonable answers to frequently asked questions. Question 1: Primary versus staged repair?
Anorectal anomalies (ARA) are characterized by different clinical presentations in both sexes with consequently different management protocols. There exist several controversies and different strategies to manage ARA in the female.
To present our experience in managing girls with ARA highlighting the rationale behind the chosen protocol.
The study included 121 girls with ARA who underwent sagittal anorectoplasty during the period 2009 through 2019. Their age ranged from 3 to 57 months (median = 7 months). There were 68 cases with rectoperineal fistula, 51 with rectovestibular fistula, 1 case with rectovaginal fistula and another case without fistula. Preoperative colostomy was performed in only 5 cases (3 rectovestibular; 1 rectovaginal; 1 without fistula). The rest of cases underwent delayed primary sagittal anorectoplasty (beyond the neonatal period).
Postoperative wound complications were detected in 14 cases (11.7%). In general, wound complications were more common among the rectoperineal group. Delayed healing problems in the form of mucosal prolapse/ectropion were detected in 10 cases. Thirty-four cases were available for delayed functional assessment. Voluntary bowel control was present in 91% of cases. Constipation was detected in 7 cases (20%) at follow up. Fecal soiling was present in 6 cases (17.6%); 3 of them were associated with constipation.
Delayed primary repair of rectoperineal and rectovestibular fistula is feasible with low complications. By adopting this protocol of management, we could achieve comparable results while avoiding unnecessary operations during the neonatal period.
This is a case series (Level IV Evidence).
30-day postoperative outcomes of neonatal versus delayed anoplasty for perineal and vestibular fistulas
2021, Journal of Pediatric Surgery
The purpose of this study was to compare the postoperative outcomes of neonatal versus delayed repair of rectoperineal and rectovestibular fistulae using a multi-center pediatric colorectal specific database. We hypothesized that the incidence of 30-day postoperative complications is not significantly different between these two surgical treatment strategies.
We performed a retrospective, observational study of the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC) database. We included any patient from the database that underwent primary surgical repair of a rectoperineal or rectovestibular fistula. Neonatal repair was defined as occurring within 14 days of birth, and delayed repair as occurring after that period. The primary outcome was the occurrence of postoperative complications within 30 days.
164 patients were included in the study (123 rectoperineal, 41 rectovestibular); the majority (81%) were repaired in a delayed fashion. Patients that underwent delayed repair had lower birth weights and were more likely to be female than those that underwent neonatal repair. Wound breakdown/dehiscence was the most common complication in both groups (Delayed 5.3% v. Neonatal, 6.5%). We found no significant difference in the incidence of any postoperative complication between groups (Delayed 6.0 v. Neonatal 6.5%, p = 1.0).
We concluded there was no significant difference in the incidence of 30-day postoperative complications for neonatal versus delayed repair of rectoperineal and rectovestibular fistulae, suggesting that both strategies are safe and may have excellent short-term outcomes in appropriately selected patients.
Comparing 30-day outcomes between early versus delayed repair of anorectal malformations with perineal or rectovestibular fistulas: An analysis of the ACS NSQIP-Pediatric database
2021, Journal of Pediatric Surgery
Anorectal malformations (ARMs) have a wide spectrum of presentation ranging from mild defects with perineal fistulas to more severe defects requiring complex management. A primary repair of ARMs with perineal or rectovestibular fistulas has been shown to have good outcomes. However, the timing of the reconstruction is still debated. The aim of this study is to investigate the safety of early versus delayed repair.
This study was performed using data from the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) from 2012 to 2017. Patients who underwent repair of anorectal malformation with perineal or vestibular fistula were included in the study. Patients with associated diagnosis for Hirschsprung disease, cloaca, rectal prolapse or stenosis, bladder exstrophy, and tracheoesophageal fistula were excluded. 30-day postoperative outcomes included wound and nonwound complications, readmissions, and reoperations. Outcomes were compared by early (≤ 7 days of age) versus delayed repair (6 weeks to 8 months).
A total of 291 patients were included, with 66 in the early and 231 in the delayed group. Patients in the early group were more likely to be male (68.2% vs 31.8%; p < 0.01) and have cardiac risk factors (71.2% vs 49.4%, p < 0.01). The mean operative time was significantly shorter in the early group (90.1 vs 129.6 min; p < 0.01). 30-day complications were not statistically significant between the two groups (p = 0.76). After multivariate analysis, timing of repair did not affect 30-day complications (p = 0.15).
Our study shows that early repair of low anorectal malformations with a perineal or vestibular fistula appears to be associated with no increase in risk of postoperative complications as compared to delayed repair. At present, the decision remains dependent on the surgeon's experience and judgment.
Level III. Retrospective comparative study.
Vacuum-assisted closure (VAC) prevents wound dehiscence following posterior sagittal anorectoplasty (PSARP): An exploratory case–control study
2021, Journal of Pediatric Surgery
Wound dehiscence (WD) of the anocutaneous anastomosis or perineal body after posterior sagittal anorectoplasty (PSARP) is common. We aimed to evaluate the efficacy of a perineal vacuum-assisted closure (VAC) for prevention of WD following repair of anorectal malformations (ARM) with rectoperineal and rectovestibular fistula.
A retrospective dual-center case–control study of children undergoing PSARP without colostomy between 2011 and 2019 was performed. The VAC group received preoperative bowel preparation (PBP), postoperative application of a VAC, loperamide (only Location A), intravenous antibiotics (IA), and total parenteral nutrition (TPN). The non-VAC group underwent PBP, loperamide (Location A), IA, and TPN without VAC. Primary outcome was WD at the anocutaneous anastomosis or reconstructed perineal body within the first 14 days after surgery.
The study population included 18 patients (VAC group) and 20 children (non-VAG group) with rectoperineal and rectovestibular fistula. The incidence of WD in the VAC group was 0% compared to 25% in the non-VAC group (0/18 vs. 5/20, p = 0.04). No VAC related complications occurred.
Postoperative application of a VAC embedded in a perioperative treatment protocol has the potential to prevent wound dehiscence of the neoanus and reconstructed perineal body following PSARP.
Case–control study.
Level III.

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Original articleAnterior or posterior sagittal anorectoplasty without colostomy for low-type anorectal malformation: how to get a better outcome?

Abstract

Background/Purpose

Materials and Methods

Results

Conclusion

Section snippets

Materials and methods

Results

Discussion

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

Original article
Anterior or posterior sagittal anorectoplasty without colostomy for low-type anorectal malformation: how to get a better outcome?