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.

Preliminary report on the International Conference for the Development of Standards for the Treatment of Anorectal Malformations.

BACKGROUND: Anorectal malformations (ARM) are common congenital anomalies seen throughout the world. Comparison of outcome data has been hindered because of confusion related to classification and assessment systems. METHODS: The goals of the Krinkenbeck Conference on ARM was to develop standards for an International Classification of ARM based on a modification of fistula type and adding rare and regional variants, and design a system for comparable follow up studies. RESULTS: Lesions were classified into major clinical groups based on the fistula location (perineal, recto-urethral, recto-vesical, vestibular), cloacal lesions, those with no fistula and anal stenosis. Rare and regional variants included pouch colon, rectal atresia or stenosis, rectovaginal fistula, H-fistula and others. Groups would be analyzed according to the type of procedure performed stratified for confounding associated conditions such as sacral anomalies and tethered cord. A standard method for postoperative assessment of continence was determined. CONCLUSIONS: A new International diagnostic classification system, operative groupings and a method of postoperative assessment of continence was developed by consensus of a large contingent of participants experienced in the management of patients with ARM. These methods should allow for a common standardization of diagnosis and comparing postoperative results.