The impact of perioperative care on complications and short term outcome in ARM type rectovestibular fistula: An ARM-Net consortium study.

BACKGROUND: The impact of perioperative care interventions on postreconstructive complications and short-term colorectal outcome in patients with anorectal malformation (ARM) type rectovestibular fistula is unknown. METHODS: An ARM-Net consortium multicenter retrospective cohort study was performed including 165 patients with a rectovestibular fistula. Patient characteristics, perioperative care interventions, timing of reconstruction, postreconstructive complications and the colorectal outcome at one year of follow-up were registered. RESULTS: Overall complications were seen in 26.8% of the patients, of which 41% were regarded major. Differences in presence of enterostomy, timing of reconstruction, mechanical bowel preparation, antibiotic prophylaxis and postoperative feeding regimen had no impact on the occurrence of overall complications. However, mechanical bowel preparation, antibiotic prophylaxis ≥48 h and postoperative nil by mouth showed a significant reduction in major complications. The lowest rate of major complications was found in the group having these three interventions combined (5.9%). Multivariate analyses did not show independent significant results of any of the perioperative care interventions owing to center-specific combinations. At one year follow-up, half of the patients experienced constipation and this was significantly higher among those with preoperative mechanical bowel preparation. CONCLUSIONS: Differences in perioperative care interventions do not seem to impact the incidence of overall complications in a large cohort of European rectovestibular fistula-patients. Mechanical bowel preparation, antibiotic prophylaxis ≥48 h, and postoperative nil by mouth showed the least major complications. Independency could not be established owing to center-specific combinations of interventions. TYPE OF STUDY: Treatment study. LEVEL OF EVIDENCE: III.

European consensus meeting of ARM-Net members concerning diagnosis and early management of newborns with anorectal malformations.

The ARM-Net (anorectal malformation network) consortium held a consensus meeting in which the classification of ARM and preoperative workup were evaluated with the aim of improving monitoring of treatment and outcome. The Krickenbeck classification of ARM and preoperative workup suggested by Levitt and Peña, used as a template, were discussed, and a collaborative consensus was achieved. The Krickenbeck classification is appropriate in describing ARM for clinical use. The preoperative workup was slightly modified. In males with a visible fistula, no cross-table lateral X-ray is needed and an anoplasty or (mini-) posterior sagittal anorectoplasty can directly be performed. In females with a small vestibular fistula (Hegar size <5 mm), a primary repair or colostomy is recommended; the repair may be delayed if the fistula admits a Hegar size >5 mm, and in the meantime, gentle painless dilatations can be performed. In both male and female perineal fistula and either a low birth weight (<2,000 g) or severe associated congenital anomalies, prolonged preoperative painless dilatations might be indicated to decrease perioperative morbidity caused by general anesthesia. The Krickenbeck classification is appropriate in describing ARM for clinical use. Some minor modifications to the preoperative workup by Levitt and Peña have been introduced in order to refine terminology and establish a comprehensive preoperative workup.

The use of human chorionic gonadotropin (HCG) for penile reconstruction in bladder exstrophy and total epispadias patients.

OBJECTIVES: The effect of intramuscular human chorionic gonadotropin (HCG) administration on penile enlargement before genital surgery, its influence on penile skin histology and testicular descent were investigated. METHODS: We examined 45 male patients (median age, 8 months; range 3-28) with total epispadias and classic bladder exstrophy, combined with cryptorchidism. 30 patients were administered 250-500 IU HCG intramuscularly 2 times per week for 3 weeks before reconstructive surgery. Skin biopsies were obtained for human epidermal growth factor (EGF) and human epidermal growth factor receptor (Her2/neu) determination. Skin specimens of the prepuce of 18 circumcised patients were used as controls. Post treatment testicle position was evaluated. RESULTS: HCG caused a mean increase in penile length of 1.8 cm (p < 0.01) and in circumference of 1.2 cm (p < 0.05) as well as improved local vascularity in all patients. Compared to the controls, the penile skin of exstrophy/epispadias patients showed a significant decrease in the average amount per field of EGF and Her2/neu positive material (controls 81% [mean 79, SE 2.3] vs. 31% [mean 28, SE 3.6; p < 0.001]). Treatment with HCG led to an increase in average EGF and Her2/neu positive material by 10% (mean 8, SE 2; p < 0.05). The potential side effects of HCG treatment were monitored 3 to 6 months postoperatively. Basal testosterone and LH levels were obtained in patients before and during therapy and postoperatively. Testicular descent was achieved in 21 patients (70%). No significant side effects or complications were encountered in any of our patients. CONCLUSION: Mean EGF and Her2/neu values are decreased in the penile skin of exstrophy/epispadias patients. The use of preoperative HCG administration leads to an increase in EGF and Her2/neu values and significantly contributes to successful reconstruction in these patients, especially in cases with a paucity of penile skin and in patients who have undergone previous repairs. Temporary penile stimulation by HCG in patients with bladder exstrophy combined with cryptorchidism allows the penile operation to be carried out earlier and contributes to testicular descent while demonstrating negligible side effects.