Analysis of the efficacy of anal dimple anorectoplasty on female infants with congenital anal atresia combined rectal vestibular fistula / 中华实用儿科临床杂志

Objective:To investigate the clinical efficacy of anal dimple anorectoplasty on female infants with congenital anal atresia combined rectal vestibular fistula.Methods:Clinical data of 69 female infants with congenital anal atresia combined rectal vestibular fistula admitted to Department of Pediatric Surgery, the First Affiliated Hospital of Zhengzhou University from July 2012 to July 2022 were retrospectively analyzed.They were divided into 2 groups according to the surgical methods: 34 cases of anal dimple anorectoplasty(group A) and 35 cases of anterior sagittal anorectoplasty(group B). The operation time, length of stay, short-term complications, long-term complications and bowel function (determined by the Rintala score at 6 months postoperatively) of the two groups were compared.The difference in the incidence of postoperative complications between groups was compared by Chi- square test, and the remaining differences between groups were compared by the paired t-test. Results:The operative time [(80.18±9.29) min vs.(103.85±8.26) min] and postoperative hospital stay[(6.10±1.52) d vs.(7.63±2.40) d] in group A were significantly shorter than those of group B ( t=11.40, 2.62; all P<0.05). The Rintala total score at 6 months postoperatively in group A was significantly higher than that of group B[(19.36±0.93) points vs.(18.76±0.44) points]( t=3.20, P<0.05). There were no significant differences in the incidences of short-term [(4/34, 11.8%) vs.(7/35, 20.0%)] and long-term complications [(2/34, 5.9%) vs.(4/35, 11.4%)]between group A and group B ( χ2=0.75, 0.75; all P>0.05). Conclusions:Anal dimple anorectoplasty for female infants with congenital anal atresia combined rectal vestibular fistula is safe and effective.

Anal ultrasonography in monitoring and postoperative evaluation of anorectal malformations

Objectives: We aimed to describe anal ultrasound for monitoring anorectal malformations.Methods: A descriptive and retrospective study of patients diagnosed and/or intervened with anorectal malformations rated by anal ultrasonography, between 2016-2017, was performed. We employed a transducer of 10 megahertz to identify the anatomy of the anal channel.Results: Eight patients, 5 men and 3 women were included, with a mean of 8.37 years old (range, 3-11). Three patients had a diagnosis of an anterior anus (not operated). Surgery was performed in 5 patients: 2 had a rectourethral fistula, 1 had a rectovesical fistula, and 1 had a rectovestibular and a perineal fistula. The most significant ultrasound findings were partial absence of the anterior part of the ex-ternal sphincter, internal sphincter hypertrophy in the middle channel, and absence of internal sphincter in the median and high channel plus the absence of external sphincter in the an-terior region. These results belonged to a patient with clinical incontinence and to 2 patients that were previously diagnosed with an anterior anus.Conclusions: Anal ultrasonography is a non-invasive method, economic, and feasible to be performed without anesthesia. It offers useful anatomical information to establish the best therapeutic option. Its main limitation is the unfeasibility of carrying it out on patients under 3 years old.

Objetivos: Describir la ecografía anal en el seguimiento de malformaciones anorrectales.Material y Métodos: estudio descriptivo y retrospectivo de pacientes diagnosticados y/o in-tervenidos de malformaciones anorrectales, evaluados por ecografía anal, entre 2016-2017. Empleamos un transductor de 10 megahercios, identificando la anatomía del canal anal alto, medio y bajo.Resultados: Se incluyeron ocho pacientes, 5 hombres y 3 mujeres, con una media de 8,37 años (rango, 3-11). Tres pacientes tenían diagnóstico de ano anterior (no operados previa-mente). Se intervinieron 5 pacientes: 2 presentaban fístula recto-uretral, 1 fístula recto-vesi-cal, 1 recto-vestibular y 1 fístula perineal.Los hallazgos ecográficos más significativos fueron: ausencia parcial de la parte anterior del esfínter externo, hipertrofia del esfínter interno en el canal medio en un paciente; y ausencia de esfínter interno en el canal medio y alto más ausencia de esfínter externo en la región anterior, en un paciente con incontinencia clínica, ambos pacientes previamente diagnosticados de ano anterior que posteriormente fueron intervenidos.Conclusiones: La ecografía anal es un método no invasivo, económico, factible de realizarse sin anestesia y ofrece una información anatómica útil para establecer la mejor opción terapéutica. Su principal limitación es la imposibilidad de realizarlo en pacientes menores de 3 años.

Long-term efficacy analysis of laparoscopic-assisted anorectoplasty for high and middle imperforate anus / 中华胃肠外科杂志

Objective@#To explore the long-term efficacy of laparoscopic-assisted anorectoplasty and conventional anorectoplasty in the treatment of children with high and middle anal atresia.@*Methods@#A retrospective cohort study was used. Inclusion criteria: (1) children with high and middle anal atresia; (2) complicated with rectourethral or rectovesical fistula; (3) complete follow-up data. Exclusion criteria: (1) complicated with 21-trisomy; (2) cerebral palsy and other mentaldisabilities; (3) Currarino syndrome; (4) FG syndrome. Clinical data of 88 patients with middle and high anal atresia, who complicated with rectourethral fistula or rectovesical fistula, and underwent anoplasty at Department of Pediatric Surgery, the First Affiliated Hospital of Zhengzhou University from January 2009 to June 2014 were enrolled in the study and analyzed. There were 24 cases with middle atresia and 64 cases with high atresia. All the cases were divided into 2 groups based on the operative method: laparoscopic group (laparoscopic-assisted anorectoplasty, 49 cases), pena group (posterior sagittal anorectoplasty, 39 cases). The demographic features of two groups were comparable. There were no statistically significant differences in gender, age, body mass, classification of anomaly types and sacral ratio (all P>0.05). Student t test and Chi square tests were used to compare the surgical conditions (operative time, postoperative hospital stay and complications), anal function (Kelly score), constipation (Krickenbeck constipation score) and anorectal pressure.@*Results@#Children of both groups all completed operation ssuccessfully. There were no statistically significant differences between laparoscopic group and pena group in the operative time [(120±31) minutes vs. (112±23) minutes, t=1.343, P=0.091] and postoperative hospital stay [(7.1±2.3) days vs. (10.7±3.3) days, t=6.021, P=1.000]. Complications were more common in the pena group [16.3% (8/49) vs. 35.9% (14/39), χ2=4.436, P=0.035]. The main complications in laparoscopic group were anal prolapse (8.2%, 4/49) and anal stenosis (6.2%, 3/49), while in pena group were anal stenosis (12.8%, 5/39) and perioperative perianal skin erosion (10.3%, 4/39). As for the anal function, the degree of feces, defecation control and sphincter contractility, the single scoring differences of Kelly scoring system were not statistically significant between the two groups, but the proportion of good function in the laparoscopic group was higher than that in the pena group [67.3% (8/49) vs. 38.5% (15/39), χ2=7.308, P=0.007]. Constipation occurred in 6 (12.2%) patients in the laparoscopic group, of whom 5 were improved by diet regulation and 1 required laxatives, while 9 (23.1%) patients developed constipation in the pena group, of whom 4 were improved by diet regulation and 5 required long-term laxatives. The difference of constipation ratio was not statistically significant (χ2=1.802, P=0.180). There were no cases of Krickenbeck constipation grade 3. Compared to the pena group, the laparoscopic group had higher anal resting pressure [(33.35±9.69) mmHg vs. (27.68±10.74) mmHg, t=2.599, P=0.011], higher dilating pressure [(9.00±5.61) mmHg vs.(6.51±3.24) mmHg, t=2.462, P=0.016], higher maximal squeeze pressure [(65.80±17.23) mmHg vs. (56.74±18.93) mmHg, t=2.389, P=0.019] and longer maximal contraction time [(21.16±5.02) seconds vs. (18.44±7.24) seconds, t=2.079, P=0.041]. The rectal resting pressure [(5.36±3.00) mmHg vs. (4.61±3.93) mmHg, t=1.015, P=0.312] was not statistically significantly different.@*Conclusions@#Compared with posterior sagittal anorectoplasty, laparoscopic-assisted anorectoplasty in the treatment of high and middle anal atresia has better long-term efficacy with less perioperative complications.

An unusual presentation of rectal atresia with rectal duplication cyst in a neonate: A case report.

A 10 days old male baby brought with abdominal distension and cystic swelling in the left buttock. Radiological investigations suggested para-rectal abscess or rectal duplication cyst. Patient underwent transverse loop colostomy and later definitive surgery by posterior sagittal approach. Intra-operative findings were suggestive of small atretic rectal segment with duplication cyst of the rectum. To the best of our knowledge, neonatal rectal atresia with rectal duplication cyst has not been reported in English literature.

Single stage Anterior Sagittal Anorectoplasty (ASARP) for Anorectal Malformations with Vestibular Fistula and Perineal Ectopic Anus in Females: A New Approach.

Introduction: Despite a better understanding of the embryology, anatomy of anorectal malformations and of the physiology of continence, the management of children born with imperforate anus continues to be a surgical challenge and is still fraught with numerous complications and often leads to less than perfect qualitative results. Pediatric patients with recto-vestibular fistula have good prognoses in terms of bowel function when properly treated. Aim & Objective: The study was designed to assess the surgical morbidity of single stage Anterior Sagittal Anorectoplasty (ASARP). Methodology: This prospective study was carried for a period of 26 months. It included a total of 48 female patients (aged 0 – 14 years) with diagnosis of Anorectal Malformations (ARM) with vestibular fistula or perineal ectopic anus. In ASARP, Patient in lithotomy position, the anterior portion of sphincter muscles were cut through a midline perineal skin incision, rectum was separated from the vagina & then rectum was pulled through the center of these muscles. The perineal body was reconstructed and the normal appearance of perineum was achieved. Results: Short-term surgical outcome was satisfactory in all cases. No one needed colostomy. Conclusion: Single-stage ASARP is a good approach in experience hands for ARM with vestibular fistula and perineal ectopic anus in females and thereby complications and time involved in staged procedures including colostomy can be avoided.

Surgical Treatment of Low and Intermediate Anorectal Anomalies by Transperineal Da- W Anorectoplasty / 实用儿科临床杂志

Objective To explore a technical modification by transperineal Da- W anorectoplasty (Da WARP) on treating low, intermediate anorectal anomalies(AA) and to evaluate the results of long - term follow up. Methods Forty six cases of AA underwent a Da-W ARP,which involved preservation of the rectal end of the fistula and invagination of the perineal skin flap through the neoanus.The clinical records were reviewed and analyzed retrospectively. Results The median follow - up period was 7 years and 2 months. All of them achieved a good fecal continence exception of 1 patient with intermediate AA and associated anomaly,had fair result. Conclusions The Da - WARP is relatively simple and practical methods for surgical treatment of low, intermediate AA, with good long - term results.

Repair of Anorectal Malformation

Major advances in the management of anorectal malformations have been achieved during the last 20 years. Alberto Pena introduced the posterior sagittal anorectoplasty (PSARP) in 1982. He divided all the sphincteric muscles at the exact posterior midline and fully exposed the crucial anatomy. He was able to manage the associated fistula under direct vision with minimal urinary tract injury. The rectum could be placed in the middle of the sphincteric muscle complex. Even with PSARP by Alberto Pena himself, only 37.5% of all cases were considered totally continent. Anorectal malformation is still acontinuing challenge for the pediatric surgeons.

Anterior Extrasphincteric Anorectoplasty with an Illuminating Intrarectal Indicator for Repair of an Anorectal Malformation

PURPOSE: This study was conducted to evaluate the functional results of an anterior extrasphincteric anorectoplasty (AEA) guided by an illuminating intrarectal indicator, in which a transperineal positioning of the anal canal was performed without cutting the perineal sphincter muscle. METHODS: Point A which would be a anal orifice in future was designated 0.3 mm anterior to the anal dimpling site. A semicircular incision was made in the front of the anus. The flap, which included from the anal skin to the upper margin of the external anal sphincter, was everted posteriorly. A quarter of the frontal upper rim of the external anal sphincter was exposed, and the center of the uppermost portion was designated as point B. From point A toward point B, a spinal needle was inserted through the anal sphincter, and needle's tract was dilated under direct identification of the sphincter muscle by electronic stimulation. An illuminating intrarectal indicator with a laparoscopic light source was pushed through the distal stoma of a sigmoid colostomy toward its distal lumen so that the blind rectal pouch was perineally exposured. On the blind pouch, a cruciate incision was made, and it was anastomosed to the anus. RESULTS: From 1991 to 2000, 11 patients with imperforate anus of high and intermediate type were operated by our method. In one case, the urethral injury was found intraoperatively and was immediately repaired. One case of anal stenosis was improved after serial Hegar dilatation. The postoperative bowel function in the Kirwan's clinical assessment at 12 th month was grade I in 9 cases and grade II in 2 case. Conclusion: This AEA with an illuminating intrarectal indicator shows acceptable clinical results and could be considered to be an effective surgical option for anorectal malformations.

Surgical Treatment of Low and Intermediate Anorectal Anomalies by Transperineal Da-W Anorectoplasty / 实用儿科临床杂志

Objective To explore a technical modification by transperineal Da-W anorectoplasty(Da-W ARP) on treating low,intermediate anorectal anomalies(AA) and to evaluate the results of long-term follow up.Methods Forty-six cases of AA underwent a Da-W ARP,which involved preservation of the rectal end of the fistula and invagination of the perineal skin flap through the neoanus.The clinical records were reviewed and analyzed retrospectively.Results The median follow-up period was 7 years and 2 months.All of them achieved a good fecal continence exception of 1 patient with intermediate AA and associated anomaly,had fair result.Conclusions The Da-W ARP is relatively simple and practical methods for surgical treatment of low,intermediate AA,with good long-term results.

Surgical Treat ment of Low and Intermediate Anorectal Anomalies by Transperineal Da -WAnorectoplasty / 实用儿科临床杂志

Objective To explore atechnical modification bytransperineal Da-Wanorectoplasty(Da-WARP) ontreatinglow,intermedi-ate anorectal anomalies(AA) andto evaluate the results of long-termfollowup.Methods Forty-six cases of AAunderwent a Da-WARP,whichinvolved preservation of the rectal end of the fistula andinvagination of the perineal skinflapthroughthe neoanus.The clinical records werereviewed and analyzedretrospectively.Results The medianfollow-up period was 7 years and 2 months.All of themachieved a goodfecal conti-nence exception of 1 patient withintermediate AAand associated anomaly,hadfair result.Conclusions The Da-WARPis relativelysimple andpractical methods for surgical treatment of low,intermediate AA,with goodlong-termresults.

Transanal Posterior Anorectoplasty of Rectal Prolapse

PURPOSE: Many different procedures for rectal prolapse have been described, but optional surgical treatment remains controversial. The aim of this report is to introduce an innovative and effective method of surgical treatment to restore anal continence and anatomic correction of rectal prolapse. METHODS: Data were retrospectively collected and analyzed on 11 patients (7 male and 4 female) who underwent transanal posterior anorectoplasty for complete rectal prolapse between Jan. 1995 to Dec. 2000. This procedure is summarized to five steps as follows: 1. Partial resection of posterior rectal ampulla. 2. Longitudinal plication with posterior fixation. 3. Posterior levatorplasty. 4. One layer suture as longitudinal fashion. 5. Gant-Miwa operation-like procedure on anterior rectum. RESULTS: There were no cases of postoperative infection and bleeding. There were no cases of recurrence of the rectal prolapse except 1 case of ant. mucosal prolapse which was successfully treated with one more Gant-Miwa operation-like procedure at postoperative 3 months. Fecal incontinence were in two cases at postoperative 12 months which were estimated as grade 2 by assessment of bowel function by Kirwan. CONCLUSIONS: Although, the best operation for rectal prolapse remains controversial subject, authors believe that transanal posterior anorectoplasty should be considered as effective new surgical procedure for the treatment of rectal prolapse.

Laparoscopically assisted anorectoplasty for intermediate imperforate anus: A report of 11 cases / 中国微创外科杂志

Objective To explore the feasibility of laparoscopically assisted one-stage anorectoplasty for the treatment of intermediate imperforate anus. Methods Under laparoscopic visualization, the rectum was mobilized. Then the rectourethral (or rectovaginal) fistula was repaired laparoscopically (6 cases) or through perineal approach (4 cases). Afterwards a tunnel was made through the center of pelvic floor musculature by combined use of laparoscopic and perineal approach. The rectum was pull-through the perineum and anastomosed with skin. At Last the colostomy was closed. Results Laparoscopically assisted anorectal pull-through was successfully performed in all cases. The mean duration of laparoscopic dissection was 32.8 minutes (range, 25~78 minutes). The mean blood loss was 5.3 ml (range, 2~10 ml). No blood transfusion was needed. The intraurethral catheter or cystostomy tube was removed on the 11th postoperative day. No intraoperative complication was encountered and all infants had uneventful postoperative recovery without wound infection. During a follow-up for 3~66 months (mean, 45 months), the fecal continence evaluation showed excellent in 8 cases and good in 3 cases. Conclusions Laparoscopically assisted anorectoplasty is an effective and minimally invasive technique for the treatment of intermediate imperforate anus. This technique has advantages of simple performance, accurate identification of the center of the pelvic floor musculature, and low infection rate.

Anterior sagittal anorectoplasty for imperforate anus with rectovestibular fistula / 中国普通外科杂志

ObjectiveTo evaluate the effects of anterior sagittal anorectoplasty(ASARP) on treating imperforate anus with rectovestibular fistula(IAFR).MethodsThe clinical data of 16 cases of IAFR treated by ASARP were analysed retrospectively.ResultsSixteen cases were followed-up for 2 months to 5 years.The anus function was assessed according to the Clinical Scoring Systems of LI Zheng.Excellent scores were obtained in 13 cases and good in 3 cases;1 patient suffered from incision infection postoperatively.ConclusionsASARP is a feasible therapy for imperforate anus with IAFR.

Long-term Results of Imperforate Anus Treated by Posterior Sagittal Anorectoplasty

PURPOSE: deVries and Pena in 1982, reported posterior sagittal anorectoplasty (PSARP) as an operative procedure for a high or intermediate imperforate anus (IA). PSARP has gained overall acceptance as a standard operative method for the repair of high and intermediate anorectal malformations. However, reports concerning the long-term outcomes of patients who have undergone a PSARP are still quite few. METHOD: To evaluate the quality of life for IA patients after a PSARP, 26 out of 43 patients who had undergone a PSARP were evaluated by using a questionnaire more than 10 years after closure of colos tomy. The questionnaire was composed of 5 categories; defecation patterns, defecation aids, social life, satisfaction, and problems after the PSARP. RESULTS: There were 23 males and 3 females. Ages were 13-26 years old. There were 17 rectourethral fistulae, 3 rectovesical fistulae, one rectal atresia, one rectovestibular fistula, and 2 rectovaginal fistulae. Follow-up periods were 12-16 years. For defecation patterns, normal defecation was observed in 62% of the patients, accidental soiling in 23%, and continuous soiling in 15%. For defecation aids, 54% of the patients used no defecation aids, 38% used enemas, and 8% used laxatives. In social life, 69% of the patients had no problems, 23% missed school, and 8% missed camp or a trip. As to the patients' own satisfaction, 81% wanted no reoperation and 19% wanted a reoperation. Problems after PSARP were reoperations for an anal transposition in 4 patients and a urethral stricture in one. CONCLUSION: PSARP resulted in good bowel control and satisfaction in the majority of IA patients, but some patients needed supportive measures and wanted a reoperation, if possible.

Posterior sagittal anorectoplasty, Secondary procedure, Anorectal malformation

Eleven patients underwent posterior sagittal anorectoplasty(PSARP) as a secondary procedure. Two of them had rectovaginal fistula and another two had rectocutaneous fistula. Six of the rest complained of frequent fecal soiling and the last one had severe anorectal stricture after perineal anoplasty. Five patients had lived with colostomy until the second operations were carried out. The ages at the time of the secondary PSARP were between 7 months and 29 years. Distal colostogram and MRI were taken to evaluate distal colon, position of the rectum and voluntary muscle. All patients had normal sacrum except one who had anorectal stricture. Seven patients, six with fecal incontinence and the other one with rectovaginal fistula had mislocated anorectums. Three patients, two with rectocutaneous fistula, the other one with anorectal stricture, had abdominal approach to obtain enough length of colon for pull-through procedure. With the posterior midsagittal approach, we could manage all the problems, rectovaginal fistulas, rectocutaneous fistulas, strictures and malpositioned rectums, without difficulty. No patients had serious complications except wound infection in one. All patients were satisfied with the results after redo-PSARPs even though normal continence has been achieved in only one patient. Seven patients who had continuous soiling or rectocutaneous fistula, needed no more diapers even though four of them showed fecal staining under stressful condition and the other three showed intermittent fecal leaking less than once a day. The rest three of the patients maintained their continence with support of drugs and/or enemas because of constipation. The PSARP is a popular procedure as a primary operation; however, our results suggested that this procedure also gave us a good opportunity for management of serious complication developed after primary anoplasties.