A case of Currarino triad with familial sacral bony deformities

Postoperative complications and long-term outcomes in Currarino syndrome

PURPOSE

This study aimed to present ten cases of Currarino syndrome, study their postoperative complications and prognosis, and analyze whether patient background and clinical factors influenced outcomes.

METHODS

Ten patients with Currarino syndrome who were followed up at our institution between 2004 and 2020 were enrolled. Patient records were retrospectively reviewed for clinical details, postoperative complications, and long-term outcomes.

RESULTS

The incidence of early postoperative complications was 80%, most of which were transient dysuria. The dysuria significantly developed in the higher normal sacral vertebra (p = 0.024) and the complete type of Currarino syndrome (p = 0.033). Later, intractable constipation requiring rectal irrigation and intractable dysuria requiring clean intermittent catheterization occurred in 40% and 30% of the patients, respectively. There was a tendency for tethered cord syndrome (p = 0.076), and the height of the normal sacral vertebra (p = 0.071) was related to intractable constipation. The height of the normal sacral vertebra (p = 0.05) and the tumor size on the image (p = 0.012) were significantly higher and larger, respectively, in the group with intractable dysuria than in the group without intractable dysuria.

CONCLUSION

Postoperative complications, especially early ones, occur at a high rate. Long-term intractable constipation and dysuria may be influenced by the degree of sacral dysplasia.

Currarino syndrome: report of five consecutive patients

INTRODUCTION

The Currarino syndrome is regarded as a developmental disorder based on its recognized etiological heterogeneity. This syndrome is thought to result from abnormal separation of the neuroectoderm from the endoderm. Our aim was to report the neurosurgical management of Currarino syndrome in children and adults and to describe what clinician could do if the Currarino triad was suspected.

CASE REPORTS

We present five cases of Currarino triad who underwent surgical intervention. All patients had sacral bony deformity, anorectal malformations, and anterior sacral meningocele. A 40-year-old-male had chronic constipation. He was incidentally diagnosed with Currarino syndrome. A 19-year-old-female suffered from a slight weakness in lower extremities and urinary incontinence. Her past medical history was remarkable for anal atresia. The other three cases were children.

CONCLUSION

When an anterior sacral meningocele is encountered, Currarino syndrome should be taken into consideration. Although it is rarity, the Currarino syndrome might be one of the causes of chronic constipation. Endoscopic or endoscope-assisted surgery via a posterior sacral route can be feasible for treatment of some of the patients with anterior sacral meningocele. Anterior meningocele pouch associated with Currarino syndrome will regresses over time following transdural ligation of its neck.

Associations of anorectal malformations and related syndromes

Anorectal malformations (ARMs) represent a complex group of congenital anomalies resulting from abnormal development of the hindgut, allantois and Mullerian duct resulting in complete or partial urorectal septal malformations. There is a wide variety of phenotypic expression, ranging from mild anorectal to very complex severe ARM with >75 % having other associated malformations. 50 % of cases are syndromic although many may have other associated anomalies. This suggests a genetic link but the genetics of ARM are highly complex with a number of candidate genes being identified. Many can be classified as "field defects" as a result of a complex set of genetic interactions. Patients with associated malformations can be classified into those with multiple congenital anomalies (non-syndromic), those with chromosomal abnormalities and those with non-chromosomal syndromic associations, also, those with non-chromosomal syndromes and the influence of environmental factors (e.g. drugs in pregnancy). Although much is not known about the aetiology of ARM, the weight of evidence points to genetic factors as major causes for the condition. In this review, we look at the chromosomal and genetic associations and their underlying signalling pathways, to obtain a better understanding of the pathogenetic mechanisms involved in developing ARM. The spectrum of ARM phenotypic expression probably results from involvement and crosstalk between a number of critical signalling systems involved in development of this region. As a result, it may be expressed as a "field developmental defect" with many associated abnormalities. The role of environmental factors in the development of ARM is probably less.

Surgical treatment of anorectal malformations

The goal of surgery for anorectal malformations (ARM) is to achieve good bowel, urinary, and sexual functions, as well as the ability for children to become healthy adults. Various surgical procedures and surgical management protocols have been explored or devised by pediatric surgeons. These are described in this review. Making a correct type classification by invertography, fistelography and urethrography in the neonatal period allows pediatric surgeons to select an appropriate surgical strategy. Surgery for low-type malformations is principally neonatal perineoplasty, while that for intermediate- or high-type malformations is colostomy, followed by a pull-through operation during infancy. Posterior sagittal anorectoplasty or laparoscopy-assisted surgery has recently been accepted as alternative procedures. Fecal incontinence represents a devastating problem that often prevents a patient from becoming socially accepted and may cause serious psychological sequelae. One-third of adult patients with high- or intermediate-type malformations occasionally complain of fecal incontinence after surgery. Most patients with ARM have normal urinary function if they do not have urinary tract or sacral anomalies. These associated anomalies also influence the prognosis for sexual function, especially in males. Some female patients have experienced normal vaginal delivery and had children. In patients with cloacal malformation, however, fertility or sexual problems are also often present. Based on this information, it is clear that only well-planned and systemic treatments can provide a good functional prognosis after making a correct classification in the neonatal period.

A case of Currarino's syndrome presenting as neonatal bowel obstruction

We describe a male infant presenting in the neonatal period with bowel obstruction who had features of anal stenosis, a presacral teratoma, and a sacral anomaly consistent with Currarino's syndrome. Initial management involved a defunctioning colostomy followed by a posterior sagittal excision of the teratoma and repair of the anorectal defect. The proband's eldest sister is also affected with features of Currarino's syndrome but was diagnosed later in life. The proband, his sister, and the mother have been identified to have the HLXB9 mutation mapped to chromosome 7q36.

New clinical and therapeutic perspectives in Currarino syndrome (study of 29 cases)

PURPOSE

The aim of the study was to clearly define the anomalies that compose the Currarino syndrome (CS). We highlight the frequency of associated malformations of the spinal cord and the possibility of a communication between the presacral tumor and the spinal canal, leading to neurological complications.

METHODS

We studied 29 patients with CS, including 12 familial cases; histological examination of the presacral tumor was performed, and cytogenetic and molecular biology studies of the HLXB9 locus were carried out.

RESULTS

All except 2 patients had a sacral malformation; 23 had an anorectal anomaly and 8 had isolated chronic intestinal pseudo-obstruction. There were 20 presacral tumors, one of which was malignant. There was a communication between the presacral tumor and the spinal canal in 12 cases, and tethering of the spinal cord in 17 cases. Twenty-five patients underwent surgery with a single-stage operation for 7, on both the intestinal and the presacral malformations, and, when required, the spinal cord anomalies. Twelve patients harbored a heterozygous point mutation of the coding sequence of HLXB9 gene.

CONCLUSION

By accurate evaluation of the 4 main features in the CS, the correct surgical management, including neurosurgery, can be performed in a 1-stage approach.

Fetal surgery for sacrococcygeal teratoma

A great deal has been learned regarding the natural history and pathophysiology of fetal SCT. The logic behind fetal intervention for SCT and hydrops appears to be correct, and open and minimal access techniques of fetal intervention have been shown to be feasible. The development of fetal intervention for SCT has mirrored those developed for other diseases such as congenital diaphragmatic hernia. In a recent presentation, Harrison, the original pioneer in fetal surgery, outlined trends in fetal intervention. The first trend is that of moving from open, invasive techniques to minimally invasive techniques. In the case of SCT surgeons are moving from open resection to RFA and possibly to fetoscopic resection. The second trend outlined by Harrison is a movement away from total in utero repair of a defect that recapitulates postnatal treatment and toward manipulation of fetal pathophysiology to reverse life-threatening events. In SCT surgeons employ RFA to ablate causative blood vessels to reverse fetal hydrops with the knowledge that these fetuses will require postnatal resection of the tumor. In contrast to resection, RFA requires less time and significantly less maternal morbidity than open resection. Further study is required to determine the role of minimal access techniques in SCT. Future directions for treatment of fetal SCT with hydrops might include fetoscopic resection or high-intensity ultrasound ablation.

Currarino triad associated with Hirschsprung's disease

The Currarino syndrome is a rare hereditary condition. The major symptom is chronic constipation from early life, and, in more than 80% of the cases, this condition is diagnosed in the first decade. The authors describe an unusual case of a complete Currarino triad associated with Hirschsprung's disease in a 6-year-old girl, presenting persistent constipation and abdominal distension. The patient is free of symptoms after surgical treatment of anorectal malformation and Hirschsprung's disease. The presacral mass was excised. Complete screening of the pelvis is recommended by using ultrasonography, computed tomography (CT) scan, and radiography in patients with a history of chronic constipation from early childhood.