Post-operative magnetic resonance evaluation of children after laparoscopic anorectoplasty for imperforate anus

Laparoscopic-assisted anorectal pull-through vs. posterior sagittal anorectoplasty for treating high anorectal malformations: a single-center experience

Background/purpose

Surgical management of high-type anorectal malformations (ARM) has evolved over the years with the widespread of the laparoscopic approach over the last two decades. This study aims to compare the outcome of patients with high anorectal malformation (ARM) managed with laparoscopic-assisted anorectal pull-through (LAARP) vs. the open posterior sagittal anorectoplasty (PSARP) at a single Institution.

Methods

A retrospective chart review of pediatric patients, who were managed for high-type ARM at our institution, was performed for the period 2000–2015. Nine were excluded because of a lack of important data. Demographic data, surgical approach, associated anomalies, and complications were collected. Functional outcome was measured using the modified clinical scoring for the defecation function of the Japanese study group of anorectal anomalies. Comparison between groups was done using the T test for continuous variables and the Fisher-exact test for proportions. P < 0.05 is considered statistically significant.

Results

There were 82 patients with high type imperforate anus (59 males and 23 females) 73% had laparoscopy vs. 27% open. Type of fistulae were rectourethral (36), rectovesical (12), no fistula (19), and (15) cloaca anomalies. Patients underwent surgery at a mean age 8.4 (laparoscopy) vs. 10.1 (open) months (P value = 0.14). There was no difference between the two groups regarding weight at the surgery or associated anomalies, except for VACTRAL and genitourinary malformations which were more among the laparoscopic group (8 vs. 1).

There was no statistical significance for all elements of defecation function score: sensation, constipation, and soiling (P values 0.17, 0.6, 0.07, respectively). There was no difference between the two groups regarding rectal prolapse (P = 0.06), whereas rectal stenosis is more in PSARP compared to LAARP (P = 0.03). The hospital stay was significantly shorter in LAARP 7.1 vs. 9.4 (P = 0.006).

Conclusions

The defecation function and complication rate for both laparoscopic and open groups were almost similar. This may justify the preference of the laparoscopic approach over the open one, given its minimally invasive nature.

Laparoscopic versus Open Pediatric Surgery: Three Decades of Comparative Studies

INTRODUCTION

 Despite its wide acceptance, the superiority of laparoscopic versus open pediatric surgery has remained controversial. There is still a call for well-founded evidence. We reviewed the literature on studies published in the last three decades and dealing with advantages and disadvantages of laparoscopy compared to open surgery.

MATERIALS AND METHODS

 Studies comparing laparoscopic versus open abdominal procedures in children were searched in PubMed/MEDLINE. Reports on upper and lower gastrointestinal as hepatobiliary surgery and on surgery of pancreas and spleen were included. Advantages and disadvantages of laparoscopic surgery were analyzed for different types of procedures. Complications were categorized using the Clavien-Dindo classification.

RESULTS

 A total of 239 studies dealing with 19 types of procedures and outcomes in 929,157 patients were analyzed. We identified 26 randomized controlled trials (10.8%) and 213 comparative studies (89.2%). The most frequently reported advantage of laparoscopy was shorter hospital stay in 60.4% of studies. Longer operative time was the most frequently reported disadvantage of laparoscopy in 52.7% of studies. Clavien-Dindo grade I to III complications (mild-moderate) were less frequently identified in laparoscopic compared to open procedures (80.3% of studies). Grade-IV complications (severe) were less frequently reported after laparoscopic versus open appendectomy for perforated appendicitis and more frequently after laparoscopic Kasai's portoenterostomy. We identified a decreased frequency of reporting on advantages after laparoscopy and increased reporting on disadvantages for all surgery types over the decades.

CONCLUSION

 Laparoscopic compared with open pediatric surgery seems to be beneficial in most types of procedures. The number of randomized controlled trials (RCTs) remains limited. However, the number of reports on disadvantages increased during the past decades.

Laparoscopically assisted anorectoplasty-Surgical procedures and outcomes: A literature review

Anorectal malformation includes various types of anomalies. The goal of definitive surgery is achievement of fecal continence. Twenty years have passed since laparoscopically assisted anorectoplasty (LAARP) was reported by Georgeson. Since LAARP is gaining popularity, its long-term outcomes should be evaluated. Presently, there is no evidence regarding the optimal method of ligating and dividing the fistula correctly and creating the pull-through canal accurately. Rectal prolapse and remnant of the original fistula (ROOF) tend to develop more often in LAARP patients than in posterior sagittal anorectoplasty (PSARP) patients; however, robust evidence is not available. Prolapse may be prevented by suture fixation of the rectum to the presacral fascia; however, if prolapse occurs, the indication, timing, and the best method for surgical correction remain unclear. Most patients with ROOF are asymptomatic, and there is controversy regarding the indications for ROOF resection. This article aimed to detail the various modifications of the LAARP procedures reported previously and to describe the surgical outcomes, particularly focusing on rectal prolapse, ROOF, and fecal continence, by reviewing the literature. Functional outcomes after LAARP were almost similar to those noted after PSARP, and we have demonstrated that LAARP is not inferior to PSARP with respect to fecal continence. Although there is controversy regarding the application of LAARP for recto-bulbar cases, we believe that LAARP is still evolving, and we can achieve better outcomes by improving the procedure.

Quality of life and defecative function 10 years or longer after posterior sagittal anorectoplasty and laparoscopic-assisted anorectal pull-through for anorectal malformation

PURPOSE

In our center, patients with anorectal malformation, including males with recto-vesical (RV)/recto-bladder neck (RBN)/recto-prostatic urethral (RU) fistulas, and females with recto-vaginal (RV) fistulas have been treated by posterior sagittal anorectoplasty (PSARP) before 2000, and by laparoscopic-assisted anorectal pull-through (LAARP) thereafter. We would like to compare the quality of life (QOL) and long-term defecative function between these two groups of patients 10 years after reconstructive surgery.

METHODS

Patients who underwent LAARP between 2001 and 2005 were compared with historical controls treated with PSARP between 1996 and 2000. Degrees of continence were graded by the Krickenbeck classification and Kelly's score. QOL was assessed by Hirschsprung's disease/Anorectal Malformation Quality of Life (HAQL) questionnaire. Results were compared using Chi-square test and t test.

RESULTS

There were 14 LAARP and 7 PSARP patients. All attained voluntary bowel movements. Moderate to severe soiling (Krickenbeck Grade 2 and 3) was found in 3/14 LAARP (21.4%) and 1/7 PSARP (14.3%) patients, p = 1.00. Constipation requiring use of laxatives was present in 3/14 LAARP (28.6%) and 1/7 PSARP (14.3%) patients, p = 0.62. Mean Kelly's scores were 3.79 ± 0.98 (LAARP) and 4.71 ± 1.25 (PSARP), p = 0.12. No patient required Malone antegrade continence enema (MACE). The QOL scores based on the HAQL questionnaire were comparable between the two groups in all areas except social functioning, in which the LAARP patients attained a significantly lower mean score (26.4 vs 71.7, p = 0.0001).

CONCLUSION

The 10-year outcome between LAARP and PSARP patients in terms of QOL and defecative function is comparable. Impairment in social functioning in these patients is reflected by the self-reported lower level of functioning.

Magnetic resonance imaging evaluation after anorectal pull-through surgery for anorectal malformations: a comprehensive review

Anorectal malformations (ARM) include congenital anomalies of the distal anus and rectum with or without anomalies of the urogenital tract. Posterior sagittal anorectoplasty (PSARP) and minimally invasive laparoscopically assisted anorectal pull-through (LAARP) procedure are now mainly used to surgically treat ARMs. Magnetic resonance imaging (MRI) is the modality of choice for interval follow-up assessment of structural and functional outcome after these surgeries to assess future bowel continence.

Well-developed pelvic musculature has been found to be a reflector of better anal continence after ARM surgery. Thus, MRI plays an important role in evaluating the external sphincter complex, puborectalis, and levator ani muscles. Other parameters that need to be noted include the position of the neoanus, rectal diameter, anorectal angle, presence or absence of megarectum, and other ancillary anomalies in the spine.

Thus, MRI due to superior soft-tissue resolution is the modality of choice and indispensable for post-operative pelvic evaluation in children.

Institutional experience with laparoscopic-assisted anorectal pull-through in a series of 17 cases: A retrospective analysis

AIMS

To retrospectively analyse the results of laparoscopically-assisted anorectal pull-through (LAARP) for high anorectal malformation (ARM) in male children in our institution.

MATERIALS AND METHODS

We analysed the hospital records of patients who had undergone LAARP from October 2010 to December 2015 in terms of age, operative time, length of hospital stay and post-operative complications.

RESULTS

Of 17 cases, 13 (76%) were in 6-12 months age group, whereas rest of them were in 12-18 months age group. The recto-prostatic urethral fistula was encountered in 82% (n = 14) of patients and rectovesical type in two cases (12%). The mean operative time was 132 min with mean length of hospital stay being 4 days. Rectal mucosal prolapse was the most common complication noted.

CONCLUSIONS

LAARP is a feasible approach to male children with high ARMs with less post-operative morbidity.

Application of anchoring stitch prevents rectal prolapse in laparoscopic assisted anorectal pullthrough

BACKGROUND

Rectal prolapse has been reported after laparoscopic assisted anorectal pullthrough in children with anorectal malformation. We report our clinical outcome and study the application of an anchoring stitch to tack the rectum to the presacral fascia and the occurrence of rectal prolapse.

MATERIAL AND METHODS

A retrospective review of all children who had undergone laparoscopic assisted anorectal pullthrough for anorectal malformation from 2000 to 2015 was performed. Patients were divided into two groups (group I: with anchoring stitch, group II: without anchoring stitch). Outcome measures including rectal prolapse, soiling, voluntary bowel control, and constipation, and Kelly Score were analyzed.

RESULTS

There were thirty-four patients (group I, n=20; group II, n=14) undergoing laparoscopic assisted anorectal pullthrough during the study period. The median follow up duration for group I and group II was 60months and 168months, respectively. All patients had stoma performed prior to the operation. Both groups consisted of patients with high type (30% vs 57%, p=0.12) and intermediate type (70% vs 43%, p=0.12) anorectal malformation. Seven (35%) patients in group I and 3 (21%) in group II had concomitant vertebral and spinal cord pathologies (p=0.408). The mean operative time was significantly shorter in group I (193±63min vs 242±49min, p=0.048). Rectal prolapse occurred less in group I, 4 (20%) vs 9 (64%) patients in group II and was statistically significant (p=0.008). Median time to development of rectal prolapse was 7months in group I and 5months in group II (p=0.767). Mucosectomy was performed in 15% of group I and 36% of group II (p=0.171). Soiling occurred less in group I (55% vs 79%, p=0.167). Voluntary bowel control (85% vs 93%, p=0.499) and constipation (55% vs 64%, p=0.601) were comparable in both groups. 75% in group I and 71% in group II achieved a Kelly score of 5 or above (p=0.823).

CONCLUSIONS

Our study showed application of anchoring stitch reduces rectal prolapse and soiling in laparoscopic assisted anorectal pullthrough. Treatment Study-Level III.

Correlation between magnetic resonance imaging findings after posterior sagittal anorectoplasty for anorectal malformations and the clinical outcome: Preliminary report

BACKGROUND/PURPOSE

To assess the anatomical results after posterior sagittal anorectoplasty (PSARP) by magnetic resonance imaging (MRI) and to evaluate the correlation of these findings with clinical outcomes.

METHODS

Patients followed-up at our center after PSARP, being at least 6year old, with neither evidence of sacral abnormalities nor spinal dysraphisms were prospectively included. Complex ARMs were excluded. MRI was performed on a 1.5T unit. T1- and T2-weighted sequences were acquired, in orthogonal planes, according to the anal canal orientation. The degree of anorectal centering in the muscle complex (DARC), the pelvic floor symmetry, the rectal maximum diameter, the fat tissue interposition, and the presence of fibrosis were evaluated. A clinical questionnaire (Rintala score) was filled in by the parents. MRI findings were compared to the clinical outcomes assessed by the Rintala score. For statistical analysis the Spearman rho correlation coefficient was calculated and the Wilcoxon rank-sum test was performed.

RESULTS

We recruited 11 patients (mean age 12years, range 6-19) with MRI. DARC (range 252-360°) was strongly correlated with the degree of fecal incontinence (rho=0.70), mildly with the ability to hold back defecation (rho=0.58), constipation (rho=0.46) and total Rintala score (rho=0.41). Pelvic floor symmetry correlated with the frequency of defecation (rho=0.58). Rectal maximum diameter negatively correlated with the ability to feel the urge to defecate (rho=-0.60). Patients with fibrosis were slightly more constipated (p=0.056) and presented more social impairment (p=0.04). Fat tissue interposition had no correlation with the clinical outcome.

CONCLUSIONS

Thanks to soft tissue definition, multiplanar imaging, and lack of ionizing radiation, MRI is a valuable tool in the postoperative anatomical evaluation of patients with ARM. Our preliminary results show that abnormal anatomical findings can correlate to a nonoptimal functional outcome, thus helping in understanding the clinical course. The degree of anorectal centering in the muscle complex (DARC) seems to have the better correlation with the outcome, especially in terms of fecal continence.

TYPE OF STUDY

Prognosis study.

LEVEL OF EVIDENCE

level IV.

Advances in minimally invasive neonatal colorectal surgery

Over the last two decades, advances in laparoscopic surgery and minimally invasive techniques have transformed the operative management of neonatal colorectal surgery for conditions such as anorectal malformations (ARMs) and Hirschsprung’s disease. Evolution of surgical care has mainly occurred due to the use of laparoscopy, as opposed to a laparotomy, for intra-abdominal procedures and the development of trans-anal techniques. This review describes these advances and outlines the main minimally invasive techniques currently used for management of ARMs and Hirschsprung’s disease. There does still remain significant variation in the procedures used and this review aims to report the current literature comparing techniques with an emphasis on the short- and long-term clinical outcomes.

Surgical management of recto-prostatic and recto-bulbar anorectal malformations

PURPOSE

Laparoscopically assisted anorectoplasty (LAARP) was compared to posterior sagittal anorectoplasty (PSARP) in the treatment of male imperforate anus associated with either recto-prostatic fistula (RPF) or recto-bulbar fistula (RBF).

METHOD

19 RPF patients (12 treated by LAARP and 7 by PSARP) and 26 RBF patients (14 treated by LAARP and 12 by PSARP) between 1995 and 2014 were retrospectively assessed using a fecal continence evaluation questionnaire (FCE) (with a maximum score of 10), an FCE score coefficient variation, as well patients' MRI scores, anorectal angle values (AA), and incidence of postoperative complications. Statistical significance was determined at p < 0.05.

RESULTS

Both groups were similar in mean age and mean weight at repair, as well as sacral status. Postoperatively, mean MRI scores, mean AA, and biochemistry were also similar (p = NS). All cases treated with LAARP showed consistently higher and less variable FCES values, fewer wound infection incidence, but greater rectal mucosal prolapse unrelated with sacrum status. Significantly lower doses of postoperative analgesia were needed in all LAARP cases (p < 0.05).

CONCLUSION

Technical outcomes appear to be similar based on imaging studies, but FCES-assessed functional outcomes appear to favor LAARP for treatment of both RPF and RBF.

Laparoscopic approach in the management of anorectal malformations

Seventeen years have passed since the first description of the laparoscopic approach for anorectal malformation and approximately 68 articles have been published on the subject. In this review article, we aim to describe the advantages as well as the indications and contraindications of this approach when dealing with each specific type of anorectal malformation, according to what has been described in the literature and to our own experience. The ideal and undisputable indication for laparoscopy remains for cases in which the abdomen needs to be entered to repair the malformation. Only 10% of male patients with anorectal malformation are born with a recto-bladder neck fistula that requires an abdominal approach, this represents an ideal indication for laparoscopy. In females, only the complex cloacae with a common channel length greater than 3 cm are the ones that require a laparotomy; they represent about 30% of the cloacae. However, the repair of this type of cloacae also requires sophisticated and technically demanding maneuvers that have never been done laparoscopically. In cases of recto-urethral prostatic fistulas the malformation can be repaired either way: laparoscopically or posterior sagitally. In all other malformations: recto-perineal fistula, recto-urethral bulbar fistula, anorectal malformation without fistula, rectal atresia, recto-vestibular fistula; no justification for laparoscopy could be found; and in some cases, laparoscopy is contraindicated. In the published reports, there is no evidence supporting the idea that laparoscopic repair results in better functional results when compared with non-laparoscopic operation; there is a tendency to omit information relevant to bowel control such as the characteristics of the sacrum and the presence or absence of tethered cord; and most authors do not compare results between comparable malformations.

Multicenter retrospective comparative study of laparoscopically assisted and conventional anorectoplasty for male infants with rectoprostatic urethral fistula

BACKGROUND

Laparoscopically assisted anorectoplasty (LAARP) was expected to achieve better fecal continence than conventional procedures. However, the issue of which approach is better remains controversial. We compared outcomes between the conventional procedure and LAARP in male infants with rectoprostatic urethral fistula.

METHODS

Institutes belonging to the Japanese Study Group of Anorectal Anomalies (JSGA) were invited to participate. Subjects were male infants with rectoprostatic urethral fistula treated by the conventional approach (abdominoperineal pull-through and PSARP) or LAARP between 2000 and 2006. Medical charts and operative records were reviewed retrospectively.

RESULTS

Eighty-one patients (conventional: 36, LAARP: 45) were enrolled from 15 centers. In both groups, the mean Kelly score was 5. The total score of the scoring system was newly developed by the Japanese Study Group of Anorectal Anomalies. Follow-up Project (5-15 points) was 10.7 and 12.1 in the conventional group and the LAARP group, respectively (p=0.07). The incidence of failed rectoanal anastomosis, mucosal prolapse, and anal stenosis was comparable in both groups. Posterior urethral diverticula were detected on cystourethrograms in 7% and 11% (p=1.0) and on MRI in 0% and 34% (p=0.02) of the conventional and the LAARP groups, respectively. Overall, 94% of diverticula were asymptomatic.

CONCLUSIONS

Fecal continence and complication rates after LAARP were comparable to those observed after the conventional method. Posterior urethral diverticula were detected more frequently after LAARP.

Laparoscopy-assisted surgery for male imperforate anus with rectourethral fistula

Laparoscopically assisted anorectal pull-through (LAARP), first described by Georgeson, is now considered to be the radical surgical treatment of choice for rectourethral fistula (RUF) in boys with high/intermediate-type imperforate anus. Accurate positioning of the pull-through canal, with pelvic floor muscles surrounding it symmetrically, is well recognized as the most important prognostic factor irrespective of the procedure performed. Surgical intervention should be LAARP with intraoperative measurement of the RUF, with follow-up focused on bowel habit. Complications such as diverticulum formation, have been reported with increasing frequency after LAARP and are most likely related to incomplete excision of the RUF, especially in bulbar cases. Thus, complete excision, while technically challenging, is crucial. Based on the results of a multicenter study comparing LAARP with other surgery, the most reliable investigation for detecting the presence of a diverticulum is MRI. At Juntendo University Hospital in Tokyo, Japan, blunt dissection with mosquito forceps to identify the potential pull-through canal, measuring the length of the RUF directly, and closer placement of trocars (in bulbar fistula cases) are homegrown refinements that we feel improve outcome and we present a review of our approach to the surgical management of ARM.

Experience with laparoscopic-assisted anorectal pull-through in 25 males with anorectal malformation and rectourethral or rectovesical fistulae: postoperative complications and functional results

INTRODUCTION

LAARP (laparoscopic-assisted anorectal pull-through) has become an established operation for anorectal malformation (ARM) with rectourethral or rectovesical fistula. The aim of this study was to review post-LAARP operation complications and midterm functional results.

METHODS

Between 2003 and 2010, we performed 28 LAARPs in ARM patients with rectourethral or rectovesical fistula. We retrospectively analyzed the clinical outcomes in 25 male patients with rectourethral or vesical fistulae.

RESULT

The mean age of the patients at the time of LAARP was 2.7 ± 1.4 months. The most common ARM type was rectoprostatic urethral fistula (n=16). Few immediate postoperative complications (urinary tract infection (1), ileus (1), and one case of pneumonia) occurred. Rectal mucosal prolapse developed and was excised 6 months later in 13 (52%) patients. Urethral diverticulum occurred in one patient with a rectobulbar urethral fistula. Immediate postoperative high rectal tone developed in six patients during the early study period (2003-2004). Six of the 12 patients older than 3 years had voluntary bowel movement and no soiling.

CONCLUSION

LAARP was a safe procedure. Shorter dissection of rectum in the intra-abdominal space may be helpful in preventing rectal mucosal prolapse. Intermittent rectal tube insertion may be useful for the patient with high rectal tone in the immediate postoperative period. LAARP is not recommended for the bulbar fistula with a long common wall.

Laparoscopic repair of anorectal malformations at the Red Cross War Memorial Children's Hospital: taking stock

BACKGROUND

The current standard repair for anorectal malformations in children is a posterior sagittal anorectoplasty. Recently, laparoscopic-assisted anorectoplasty (LAARP) was performed at the Red Cross Children's Hospital.

METHODS

A detailed case note review was conducted. Patient outcome was prospectively evaluated by colorectal nurse specialists using the Krickenbeck standardized questionnaire. Comparison among patients undergoing posterior sagittal anorectoplasty was performed.

RESULTS

Between September 2005 and June 2009, 24 children underwent LAARP. Sixteen had associated anomalies, including 7 children with renal and 4 children with cardiac abnormalities. Median age at surgery was 7.5 months (range, 2.6-15.0 months). Subtypes of anorectal malformation were as follows: vestibular, 2; bulbar, 9; prostatic, 7; vesical, 3; and with no fistula, 3. There was a 16% early complication rate. Redo-anoplasty was required in 9 patients. Eleven children had difficulties with follow-up. Thirteen children had regular follow-up and were analyzed further. Toilet training had been completed in 7 children (median age, 4.3 years; range, 3.5-6 years). Six children developed voluntary bowel motions. Six children are awaiting toilet training or are unable to train because of incontinence.

CONCLUSIONS

Anal stenosis was the most common complication post-LAARP. Etiology appeared to be multifactorial, but poor compliance with dilatations was a leading cause.

Evaluation of defecative function 5 years or longer after laparoscopic-assisted pull-through for imperforate anus

BACKGROUND

Laparoscopic anorectoplasty was introduced in 2000, but the procedure has not yet gained universal acceptance. Previous studies, including ours, reported satisfactory early postoperative outcome as compared with posterior sagittal anorectoplasty (PSARP), but mid- to long-term results are not available. Here, we aim to evaluate the mid- to long-term defecative function in these patients.

MATERIALS AND METHODS

A retrospective study was carried out and included all patients who underwent laparoscopic-assisted anorectoplasty for high-/intermediate-type imperforate anus between 2001 and 2005. Their degree of continence was graded according to the Krickenbeck classification and compared with historical controls treated with PSARP. The results were compared using χ(2) test, and P < .05 was considered statistically significant.

RESULTS

There were 18 patients who underwent laparoscopic anorectoplasty (LAR) in the study period. They were compared with 20 historical PSARP patients. For defecation sensation, 16 of the 18 LAR patients were positive, whereas there were 16 of 20 PSARP patients. Eight LAR patients were clean without any fecal soiling or incontinence (11/20 PSARP). Only 3 of 18 LAR had constipation as compared with 7 of 20 PSARP. The need for rectal enema for evacuation was seen in 1 of 20 LAR patients and 2 of 20 PSARP patients (for all categories, P > .05).

CONCLUSIONS

Mid- to long-term follow-up study revealed satisfactory defecative function for patients with high-/intermediate-type imperforate anus after LAR. The outcome is at least as good as PSARP. Longer term follow-up with larger sample size is necessary to demonstrate the benefits of LAR over PSARP.

Laparoscopically assisted anorectal pull-through for high imperforate anus in infants: intermediate results

PURPOSE

The aim of this study was to evaluate the clinical outcomes and postoperative anal function in infants with congenital high imperforate anus treated with laparoscopically assisted anorectal pull-through (LAARP).

METHODS

From January 2004 to July 2007, 33 patients (28 boys and 5 girls, age ranging from 3 to 10 months) with high imperforate anus underwent LAARP. Clinical data of the LAARP group were retrospectively compared with those treated by posterior sagittal anorectoplasty (PSARP; n = 28) during the same time period. Anorectal function of these patients was evaluated using the following 3 methods: the Kelly score, anorectal vector volume manometry, and magnetic resonance imaging between the ages of 3.1 and 4.4 years.

RESULTS

The mean operative time in LAARP and PSARP groups was 112.5 ± 12.4 and 120.4 ± 18.5 minutes (P > .05), respectively. The mean length of hospital stay in the LAARP group was shorter than that of PSARP group (11.3 ± 2.1 vs 14.6 ± 2.3 days, P < .01). No significant difference was observed between LAARP and PSARP groups regarding the Kelly score (3.52 ± 1.42 vs 3.49 ± 0.82). Although magnetic resonance imaging revealed lower malposition rates of rectum in the LAARP group than those of the PSARP group at both I-line (3.0% vs 14.3%) and M-line (3.0% vs 10.7%) levels, this was not statistically different (P > .05). Compared with the PSARP group, lower asymmetric index, larger vector volume, and higher anal canal pressure at rest and during voluntary squeeze were observed in LAARP group (P < .05). However, there were no significant differences in the length of high-pressure zone (15.2 ± 5.8 vs 15.1 ± 6.2 mm) and the presence of rectoanal relaxation reflex (84.8% vs 85.7%).

CONCLUSIONS

Satisfactory fecal continence can be achieved in patients with high-type imperforate anus after LAARP. Laparoscopically assisted anorectal pull-through has advantages over PSARP, including shorter hospital stay and better position of rectum. However, long-term follow-up is necessary to compare the benefits of LAARP against PSARP.

Laparoscopy and its use in the repair of anorectal malformations

INTRODUCTION

Laparoscopy has been used for the treatment of anorectal malformations (ARMs) in an attempt to be less invasive and with the hope that it would result in a better functional outcome. There remains a significant debate about whether these expectations have been fulfilled.

METHODS

Seventeen patients with ARM for whom laparoscopy was used were retrospectively reviewed. Six were operated on primarily by the authors, and 11 cases were referred after a laparoscopic repair performed elsewhere. In addition, a literature review was performed looking for evidence of less invasiveness and improved functional results in patients operated on laparoscopically.

RESULTS

The diagnosis was imperforate anus with a rectobladder neck fistula in our 6 cases with the fistula ligated laparoscopically in each case. In 1 patient, the malformation was repaired entirely using laparoscopic technique. The other 5 patients had a laparoscopically assisted repair because we had to open the abdomen to taper a dilated rectum in 2, mobilize a very high rectum in 2, and take down a distal colostomy stoma in 1. Eleven patients were referred with a variety of problems after a laparoscopic repair done elsewhere for rectal stricture (5), rectal prolapse (4), recurrent rectourethral fistula (3), rectal mislocation (3), failed attempted repair leading to fecal incontinence (1), and a posterior urethral diverticulum (1). Our literature review included 47 references (involving 323 patients) published between 1998 and 2010. All studies showed that laparoscopic repair of ARMs is feasible. The review, however, did not provide evidence of less invasiveness or improved functional results.

CONCLUSIONS

Laparoscopy for ARM is a less invasive procedure when compared with those operations that would have previously required a laparotomy (rectobladder neck fistula). In cases of rectoprostatic fistulae, the laparoscopic approach is feasible and avoids a lengthy posterior sagittal incision. There is no evidence that the laparoscopic approach is a less invasive procedure for other types of ARMs. In cases of rectobulbar fistula, congenital anal stenosis, perineal fistula, ARM without fistula, the evidence suggests that it may be lead to more complications. There is no evidence in the literature demonstrating better functional results in cases of ARM operated on laparoscopically.

Comparison of anorectal angle and continence after Georgeson and Peña procedures for high/intermediate imperforate anus

AIM

The anorectal angle (AA) influences defecation after pull-through (PT) for imperforate anus (IA). We compared postoperative AA and continence after Georgeson's laparoscopy-assisted colon PT (GPT) and Peña's posterior sagittal anorectoplasty (PSARP) for high/intermediate-type IA.

METHODS

We reviewed 33 high/intermediate-type IA cases (20 GPTs and 13 PSARPs) prospectively. All had colostomy initially as neonates. Anorectal angle was measured as the angle between the rectum and the anal canal on barium enema. A fecal continence evaluation questionnaire (FCEQ) consisting of 5 parameters (frequency of defecation, staining/soiling, perianal erosion, anal shape, and requirement for medication; maximum score = 10) was evaluated in 28 cases (15 GPTs and 13 PSARPs) followed up for more than 3 years.

RESULTS

Mean age at PT was similar (6.6 months for GPT and 6.3 months for PSARP; P = not significant). There was no significant difference in mean AA. The FCEQ scores for GPT were generally higher throughout the study and significantly better from 3 years postoperatively (P < .05).

CONCLUSIONS

We are the first to confirm that effective AA similar to PSARP can be achieved after GPT, although FCEQ would suggest that GPT has less detrimental functional impact.

Laparoscopic-assisted anorectal pull-through for anorectal malformations: a systematic review and the need for standardization of outcome reporting

INTRODUCTION

Laparoscopic-assisted anorectal pull-through (LAARP) is becoming an increasingly common procedure to correct high and intermediate anorectal malformations (ARMs). The aim of this review was to evaluate worldwide experiences with LAARP with regard to indications, outcomes, and quality of reporting.

METHOD

A systematic review was conducted. The search was limited to studies reported in English and performed in humans. In addition to Medline and PubMed, a manual search of the Journal of Pediatric Surgery, Pediatric Surgery International, Surgical Endoscopy, and the Journal of Laparoendoscopic & Advanced Surgical Techniques published between June 2000 and April 2008 was conducted.

RESULTS

Seventeen studies were included in the final analysis. Of the included studies, none were randomized, 2 were prospective in nature, and 4 compared outcomes of posterior sagittal anorectoplasty and LAARP. The studies included 124 patients (96 males, 28 females) with 80% reported as having high/intermediate malformations. All studies reported short-term outcomes. Reported outcomes included continence, rectal prolapse, the position of the rectum (7 studies using Kelly score), manometry (1 study), contrast enema (1 study), postanal endosonography (3 studies), and postoperative magnetic resonance imaging (3 studies). Outcomes varied widely between reports precluding a meta-analysis.

CONCLUSION

The number of studies dealing with LAARP is low. There is a need for both a standardization and improvement in the quality of reporting in LAARP research. This will ultimately allow for evidence-based surgical decision making.

Advances in pediatric colorectal surgical techniques

The operative management of pediatric colorectal diseases has improved significantly in recent years through the development of innovative approaches for operative exposure and a better understanding of colorectal anatomy. Advances in transanal and minimal access techniques have formed the cornerstone of this innovation, leading to improved functional outcomes, earlier recovery, and superior cosmetic results for a number of colorectal diseases. In this regard, we have witnessed a significant evolution in the way that many of these conditions are managed, particularly in the areas of anorectal malformations and Hirschsprung disease. Furthermore, a more thorough understanding of the pathophysiology underlying encopresis and true fecal continence has led to novel and less invasive approaches to the operative management of these conditions. The goal of this review is to describe the evolution of operative management pertaining to these diseases, with an emphasis on technical aspects and relevant clinical pitfalls.

Magnetic resonance imaging-guided laparoscopic-assisted anorectoplasty for imperforate anus

PURPOSE

Magnetic resonance imaging (MRI) has been well described as a modality for evaluation of a failed anorectal pull-through procedure for imperforate anus. To the authors' knowledge, intraoperative MRI has not been previously used to guide a laparoscopic-assisted anorectoplasty (LAARP). We propose that such a procedure would assure anatomically correct placement of the pulled-through rectum.

METHODS

Three male patients with imperforate anus and a prostatic urethral fistula underwent an MRI-guided LAARP in an operative MRI suite. The patients' ages ranged from 5 to 6 months at the time of their pull-through procedure. Preoperative MRIs with mineral oil within the distal colostomy were performed on all patients to document the anatomy of the rectourethral fistula and its relationship to the parasagittal and vertical muscle complex. The perineum was pierced with an MRI compatible needle at the central portion of the parasagittal muscle complex as determined by a direct muscle stimulator. Further incremental advancement of the needle within the muscle complex was guided by serial MRIs in axial, coronal, and sagittal planes until the levator floor was penetrated, and the peritoneal cavity was entered. LAARP was then completed.

RESULTS

Completion MRI demonstrated placement of the pulled-through segment in a central location through the length of the muscle complex. Serial MRIs performed intraoperatively during advancement of the localization needle demonstrated a curved path of the vertical fibers. Attempts to nonincrementally advance the needle in a straight plane resulted in a breach of the vertical muscle complex or eccentric placement of the needle.

CONCLUSIONS

Magnetic resonance imaging-guided LAARP results in anatomically correct placement of the rectum within the vertical muscle complex. Straight needle advancement techniques in LAARP could result in a deviation of the pulled-through rectum from the central muscular path. Further follow-up will be required to demonstrate functional advantage.

Division of the fistula in laparoscopic-assisted repair of anorectal malformations-are clips or ties necessary?

BACKGROUND

Laparoscopic-assisted anorectoplasty (LAARP) was introduced in 2000 by Georgeson (J Pediatr Surg. 2000;35:927-930) and has gained interest because of improved visualization of the rectal fistula and the ability to place the pull-through segment within the levator muscle complex with minimal dissection. Currently, there is no consensus on how the fistula should be managed during LAARP. We postulated that the fistula could be managed with simple division and temporary diversion of urine through a Foley catheter without surgical ligation of the fistula similar to the management of a traumatic urethral injury.

METHODS

A retrospective chart review was performed of patients with imperforate anus who underwent LAARP between January 2005 and September 2007.

RESULTS

Eight patients were managed with a LAARP. Five male patients had the fistula simply divided. In these 5 patients, the location of the fistula was rectoprostatic (2) and rectobulbar (3). The Foley catheter was left in position until a retrograde urethrogram demonstrated no evidence of a leak (range, 6-40 days). There were no postoperative urethral strictures and one diverticulum. Follow-up has ranged from 10 to 19 months.

CONCLUSION

Male patients with a rectourethral fistula at or just below the prostate can be safely and successfully managed with simple division of the fistula.

Evaluation of outcome of anorectal anomaly in childhood: the role of anorectal manometry and endosonography

The aim of this study was to evaluate role of anorectal manometry (ARM) and anal endosonography (ES) in assessment of the internal anal sphincter (IAS) quality on continence outcome following repair of anorectal anomalies (ARA). We devised a scoring system to evaluate the quality of the IAS based on ARM and ES and correlated the scores with clinical outcome, using a modified Wingfield score (MWS) for faecal continence. We also assessed the implication of megarectum and neuropathy on faecal continence. Of 54 children studied, 34 had high ARA and 20 had low ARA. Children with high ARA had poor sphincters on ES and ARM, and also poor faecal continence compared to those with low ARA. The presence of megarectum and neuropathy was associated with uniformly poor outcome irrespective of the IAS quality. The correlations between MWS on one hand, and ES and ARM scores for IAS on the other hand were weak in the whole study group, ES r = 0.27, P < 0.04, and ARM r = 0.39, P < 0.004. However, the correlations were strong in those who had isolated ARA without megarectum or neuropathy, ES r = 0.51, P < 0.02 and ARM r = 0.55, P < 0.01, respectively. In conclusion, the ARM and ES are valuable in evaluation of continence outcome in children after surgery for ARA and those with good quality IAS had better faecal continence. The IAS is a vital component in functional outcome in absence of neuropathy and megarectum.

Minimally invasive surgery in infants less than 5 kg: experience of 649 cases

INTRODUCTION

With the development of advanced skills and the introduction of miniature laparoscopic tools, endoscopic procedures in infants and small children have become possible. This report documents our experience in minimally invasive surgery (MIS) in infants under 5 kg.

METHODS

A retrospective database review was performed from September 1993 to September 2007. All children weighing 5 kg or less that underwent a laparoscopic or thoracoscopic procedure were included.

RESULTS

A total of 649 cases were attempted. 43 different procedures were performed, the most common being Nissen fundoplication (310 cases, average operating room (OR) time 43 min, average time to full feeds 2 days), pyloromyotomy (104 cases, average OR time 12.5 min, average hospital days<1), patent ductus arteriosum (PDA) ligation (26 cases, average OR time 31 min, average hospital days<1), tracheoesophageal fistula (TEF) repair (22 cases, average OR time 83 min, average time to full feeds 7.8 days), duodenoduodenostomy (20 cases, average OR time 76 min, average time to full feeds 8.6 days), colonic pull-through for Hirschsprung's disease (18 cases, average OR time 109.6 min, average time to full feeds 3 days), colonic pull-through for imperforate anus (10 cases, average OR time 103 min, average hospital days 2), lung resection (12 cases, average OR time 66.8 min, average hospital days 1.75), congenital diaphragmatic hernia repair (10 cases, average OR time 62.5 min, average time to full feeds 4.75 days). There were no surgery-related deaths. The conversion rate to open was 1.2% (n=8). There were six intraoperative complication rate (0.9%) and the overall complication rate was 3% (20 complications overall).

CONCLUSIONS

The development of modern low-flow CO2 insufflators, smaller instruments and telescopes, as well as advanced techniques, has made MIS in neonates feasible and safe. The greatest challenge remains performing intestinal anastomosis in these confined spaces, and further technical advances will be required to make these techniques universally adopted.

[Morphologic evaluation of fecal incontinence by magnetic resonance imaging in patients with corrected anal atresia]

PURPOSE

To describe the findings obtained with magnetic resonance imaging (MRI) in patients with ano-rectal atresia, after treatment by posterior sagittal anorectoplasty (PSARP), who have fecal incontinence and to describe its usefulness in the evaluation of causes of incontinence.

SUBJECT AND METHODS

Twelve patients, 9 men and 3 women, with anorectal atresia were examined with 0.5T MRI after performing PSARP for imperforate anus. The study included T1-weighted, T2-weighted and proton-density, axial, sagittal and coronal planes. The location of descended neorectus and the degree of development of pelvic musculature were evaluated.

RESULTS

Normal development of anus levator muscles and sphincterian complex were observed in six patients, with correct situation of neorectus between anus levator muscles and sphincterian complex in five of them and eccentric in the other one. Diverse grades of striate muscular complex underdevelopment were showed in the other six cases, moderate grade in four of them and severe hypoplasia in the other two. Spinal and urogenital congenital anomalies were found in these patients. Sagittal and coronal T1-weighted MR images were the most useful planes in evaluating the relationship between anus levator muscles and sphincterian complex and axial T1-weighted MR images in the evaluation of the level of development of striated muscle complex in the evaluation of patients.

CONCLUSIONS

MRI is useful in the evaluation of patients with fecal incontinence after performing PSARP for anorectal atresia. Unsuitable neorectus position or striated muscle complex hypoplasia are causes of postoperative incontinence in these patients.

Midterm postoperative clinicoradiologic analysis of surgery for high/intermediate-type imperforate anus: prospective comparative study between laparoscopy-assisted and posterior sagittal anorectoplasty

PURPOSE

The objective of this study is to analyze the outcome of surgery for high/intermediate-type imperforate anus using anal endosonography (AES), magnetic resonance imaging (MRI), and a continence evaluation questionnaire (CEQ).

METHODS

In this study, 24 cases of high/intermediate-type imperforate anus were studied. Fifteen of 24 had Georgeson's laparoscopy-assisted anorectoplasty (GLA), and 9 of 24 had Pena's posterior sagittal anorectoplasty (PPA). All subjects had AES and MRI postoperatively. On AES, differences in thickness of the external sphincter (ES) and puborectalis (PR) at 3 and 9 o'clock were compared, and if pull-through colon was central, AES was 0. On MRI, differences in thickness were analyzed semiquantitatively and scored; if muscles were of even thickness, the score was 0; slight difference was 1, and marked difference was 2. A 5-parameter CEQ questionnaire (maximum score, 10) was administered to 16 of 24 subjects followed up for more than 3 years (9 GLA, 7 PPA). Surgical stress was assessed using mean febrile period, duration of raised white blood cell count, and peak C-reactive protein level.

RESULTS

Mean age at surgery and mean postoperative period for both groups were not statistically different. There were no differences in mean muscle thickness for ES or PR on AES according to procedure (ES: GLA = 0.19 +/- 0.15 mm, PPA = 0.16 +/- 0.09 mm, P = .59; PR: GLA = 0.19 +/- 0.19 mm, PPA = 0.22 +/- 0.15 mm, P = .69). Magnetic resonance imaging scores were also not significantly different according to procedure (GLA: 0.77 +/- 0.83; PPA: 0.75 +/- 0.50, P = .97). When CEQ were compared annually, scores for GLA were generally higher throughout the study but only statistically significant at 3 and 4 years (P < .05). Differences in parameters of surgical stress were not significant.

CONCLUSION

Although there were no differences in muscle thickness and parameters of surgical stress observed according to technique, GLA would appear to provide better outcome based on CEQ scores.

Primary laparoscopic repair of high imperforate anus in neonatal males

PURPOSE

The standard approach to males with high imperforate anus has been a staged procedure starting with a descending colostomy, then posterior sagittal anorectoplasty with colostomy closure after 3 months. Recently, a minimally invasive approach to the repair of high imperforate anus has been described in infants after colostomy. We describe 6 newborn males with high imperforate anus successfully repaired laparoscopically as a primary, single-stage procedure.

METHODS

A retrospective chart review was performed on all patients with imperforate anus from October 2003 to October 2006.

RESULTS

We evaluated 9 newborn males with high imperforate anus. Of these patients, 6 underwent primary laparoscopic repair on day 1 to day 2 of life. Of these 6 patients, 3 were found to have bladder neck fistulas, whereas the other 3 had prostatic urethra fistulas. All patients passed stool within the first 72 hours postoperatively. One patient has required a procedure for a mild rectal prolapse. Follow-up ranges from 2 to 30 months in the single-stage group.

CONCLUSION

Our early results using primary laparoscopic repair appear encouraging. Laparoscopy allows excellent visualization and assessment of the fistula and repair of high imperforate anus without need for colostomy. Long-term follow-up will be needed to assess outcomes and continence rates.

Laparoscopic-assisted anorectal pull-through

Posterior sagittal anorectoplasty (PSARP) is the procedure most commonly employed to repair high and intermediate anorectal malformations. Many patients repaired by PSARP subsequently require bowel management to avoid the physiologic and social problems associated with fecal incontinence. Laparoscopic assisted anorectal pull-through (LAARP) is a recently developed technique which positions the neorectum accurately inside the sphincter complex without dividing any of these muscles. Some physiologic measurements after LAARP indicate that outcomes are at least equivalent to PSARP. Long-term outcomes have not been reported after LAARP.

Anal endosonography is useful for postoperative assessment of anorectal malformations

AIM

This study aimed to develop and evaluate a scoring system for anal endosonography to assess anal canal structures after repair of anorectal malformations (ARM).

METHODS

Forty patients with ARM aged 16 years (range, 1-22 years) and 20 controls aged 17 years (range, 0.5-20 years) were examined. Anal function was assessed clinically and by anal canal manometry. The anal canal structures were imaged by anal endosonography using a 7.5-MHz transducer. A scoring system was developed to assess the anal sphincters as visualized on the endosonographic images.

RESULTS

Continence was significantly correlated to anal canal pressures. The estimated extent of muscle defect (measured in quadrants) and the number of disruptions in the internal and external anal sphincters correlated significantly to the rest and squeeze pressures, respectively. Thus, patients (>4 years) with squeeze pressure of less than 80 cm H2O were characterized by more than 1 disruption in the external anal sphincter ring and 2 or more quadrants with scar tissue.

CONCLUSION

The extent of scar tissue and the number of disruptions in the anal sphincters correlate with anal canal pressures and continence after ARM repair. Anal endosonography may be used to study the results after different surgical techniques and for prognosis on continence in patients with ARM.