Improving the rigour of VACTERL screening for neonates with anorectal malformations.

PURPOSE: Screening investigations for the vertebral, anorectal, cardiac, tracheo-oesophageal, renal and limb (VACTERL) association form an important part of the management of neonates with anorectal malformations (ARMs). We developed a proforma to define investigations and indications for referral. The aim of the current study was to determine if the proforma could improve screening rigour. METHODS: Four centres performed a 3-year retrospective audit of neonates with ARM. Following introduction of a proforma, the same data were collected prospectively for consecutive neonates over a further 2 years. The appropriate investigation of each component of the VACTERL association and the corresponding referral required for each abnormal result were defined. The proportion of patients undergoing appropriate investigation and referral was compared against these standards. An audit standard of 90% was set for each criteria. RESULTS: Prior to implementation of the proforma, 86 patients were audited, with a further 69 patients after. The audit standard was met in 7 criteria before introduction of the proforma in comparison to 10 criteria afterwards. CONCLUSION: The completeness of VACTERL screening and its documentation improved following introduction of the proforma. Performance remains imperfect. Review of specific criteria (such as definition of vertebral body screening) will help address this.

Reversal of loop ileostomy under spinal anaesthesia.

BACKGROUND AND AIMS: Traditionally, loop ileostomy is reversed under general anaesthetic. In patients with severe cardiorespiratory disease, many surgeons opt for a one-stage, low Hartmann's procedure to avoid a second general anaesthetic to reverse a defunctioning stoma. Closure of loop ileostomy under spinal anaesthetic would allow high-risk patients to avoid a permanent stoma and a general anaesthetic. PATIENTS AND METHODS: Seven patients (6 of whom were men) had reversal of loop ileostomy under spinal anaesthetic. The median age was 63 years (range 43--70). Six patients had significant co-morbidity with a median American Society of Anesthesiologists (ASA) grade of 3. The ileostomy was reversed in a side-to-side fashion using a linear stapler. The small bowel wall was infiltrated with local anaesthetic prior to firing the stapler. RESULTS AND FINDINGS: All patients tolerated the procedure without discomfort. Patients started feeding on the first postoperative day. Analgesia requirements postoperatively were minimal. No complications occurred due to the anaesthetic technique. CONCLUSION: With careful patient selection, preparation and a gentle and meticulous surgical technique, reversal of loop ileostomy can be achieved under spinal anaesthesia, thereby, saving high-risk patients with low tumours (suitable for sphincter preservation) from having a one-stage resection with permanent stoma.