Surgical treatment of anorectal malformations. Surg Today. 2013;43:955-962. [PMID: 23196862 DOI: 10.1007/s00595-012-0435-y]

New ultrasound features in diagnosing fetal anal atresia: a multicenter prospective cohort study

This research aimed to assess the validity of ultrasound scans with new features in detecting fetal anal atresia and verify the effectiveness of these new features. Additionally, we aimed at investigating the perinatal incidence of anal atresia. This multicenter prospective study recruited 94,617 normal gravidas and 84 gravidas with anal atresia fetuses. The gold standard for diagnosing perinatal anal atresia is routine neonatal anus examinations. The incidence calculation was based on the results of the gold standard. The validity of our new approach was evaluated via a diagnostic test involving all 94,701 subjects. The effectiveness of our new features was assessed through an ablation study in a randomly established new dataset, with the ratio of anal atresia to non-anal atresia cases of 1:4. The annual perinatal incidence of anal atresia between 2019 and 2023 ranges from 0.57‰ to 1.29‰. Our new method performed great regarding the Youden index, diagnostic odds ratio (DOR), area under the curve (AUC) of the receiver operating characteristic curve (ROCC), AUC of the precision-recall curve (PRC), F1-score, and Cramer's V. In the ablation study, our new approach surpassed its competitors concerning Youden index, DOR, AUC of the ROCC, and AUC of the PRC. Ultrasound scans show high validity and clinical value in detecting fetal anal atresia. Our new ultrasound features significantly promote the detection of fetal anal atresia.

Comparing Loop and Divided Colostomy for Anorectal Malformation: A Systematic Review and Meta-Analysis

INTRODUCTION

The optimal type of colostomy for patients with anorectal malformations (ARM) remains unclear. We conducted a systematic review and meta-analysis to compare the clinical outcomes of loop colostomies (LC) versus divided colostomies (DC) in patients with ARM.

METHODS

After review registration (PROSPERO: CRD42024513335), we searched multiple databases for comparative studies on LCs and DCs in patients with ARMs. Gray literature was sought. The complications examined included stoma prolapse, urinary tract infection (UTI), skin excoriation, stoma retraction, parastomal hernia, wound infection rate, and stoma stricture. Three reviewers independently assessed the eligibility and quality of the included studies. Meta-analysis of selected complications was performed using Revman 5.4, with p < 0.05 considered significant.

RESULTS

Eleven studies were included in the analysis, incorporating a total of 2550 neonates with ARMs, of which 1147 underwent LCs and 1403 underwent DCs. The meta-analysis revealed no significant differences between the two groups in the incidence of stoma prolapse (OR: 1.55, 95 % CI: 0.63 to 3.79; p = 0.34), UTIs (OR: 1.78, 95 % CI: 0.50 to 6.36; p = 0.38), skin excoriation (OR: 1.26, 95 % CI: 0.68 to 2.34; p = 0.46), stoma retraction (OR: 0.79, 95 % CI: 0.09 to 6.64; p = 0.83), parastomal hernia (OR: 0.99, 95 % CI: 0.22 to 4.48; p = 0.99), wound infection (OR: 0.35, 95 % CI: 0.10 to 1.20; p = 0.10), and stoma stricture (OR: 0.70, 95 % CI: 0.22 to 2.18; p = 0.53).

CONCLUSIONS

The findings suggest that LCs and DCs are viable options for fecal diversion, presenting similar risks and benefits. The choice between these techniques should consider individual patient characteristics and surgical expertise.

TYPE OF STUDY

Meta-analysis.

LEVEL OF EVIDENCE

II.

Spatial transcriptomics reveals gene interactions and signaling pathway dynamics in rat embryos with anorectal malformation

Anorectal malformation (ARM) is a prevalent early pregnancy digestive tract anomaly. The intricate anatomy of the embryonic cloaca region makes it challenging for traditional high-throughput sequencing methods to capture location-specific information. Spatial transcriptomics was used to sequence libraries of frozen sections from embryonic rats at gestational days (GD) 14 to 16, covering both normal and ARM cases. Bioinformatics analyses and predictions were performed using methods such as WGCNA, GSEA, and PROGENy. Immunofluorescence staining was used to verify gene expression levels. Gene expression data was obtained with anatomical annotations of clusters, focusing on the cloaca region's location-specific traits. WGCNA revealed gene modules linked to normal and ARM cloacal anatomy development, with cooperation between modules on GD14 and GD15. Differential gene expression profiles and functional enrichment were presented. Notably, protein levels of Pcsk9, Hmgb2, and Sod1 were found to be downregulated in the GD15 ARM hindgut. The PROGENy algorithm predicted the activity and interplay of common signaling pathways in embryonic sections, highlighting their synergistic and complementary effects. A competing endogenous RNA (ceRNA) regulatory network was constructed from whole transcriptome data. Spatial transcriptomics provided location-specific cloaca region gene expression. Diverse bioinformatics analyses deepened our understanding of ARM's molecular interactions, guiding future research and providing insights into gene regulation in ARM development.

Comparison of postoperative urinary complications in laparoscopic-assisted anorectoplasty versus posterior sagittal anorectoplasty for anorectal malformation with rectourethral fistula

BACKGROUND

Long-term urinary outcomes after anorectal malformation (ARM) repair are affected by surgical approach and sacral anomalies. This study aimed to compare laparoscopic-assisted anorectoplasty (LAARP) and posterior sagittal anorectoplasty (PSARP) in terms of urinary complications.

METHODS

Between 2001 and 2022, 45 patients were treated with LAARP or PSARP. The rectourethral fistula and inflow angle between the fistula and rectum was confirmed by preoperative colonography. The incidence of urinary complications and treatment were compared between the two groups.

RESULTS

Four patients (14%) had remnant fistula and five patients (17%) had neurogenic bladder dysfunction in LAARP group, while three patients (18%) had urethral injury in PSARP group. All patients with remnant fistula were asymptomatic and followed without treatment. The incidence of remnant fistula improved between earlier decade and later decade. In all cases with urethral injury, suture repair was performed and no postoperative leakage was noted. All five patients with neurogenic bladder dysfunction had spine abnormalities that required clean intermittent catheterization (CIC) and two were free from CIC finally.

CONCLUSIONS

It is important to check inflow angle preoperatively to prevent remnant fistula. For PSARP, meticulous dissection is required when separating fistula from urethra because they create common wall. The most contributing factor to neurogenic bladder is sacral anomalies. Preoperative evaluation and postoperative urinary drainage are important.

A Study of the Clinical Profile and Management of Children With Anorectal Malformations

Introduction The diagnosis of anorectal malformations (ARMs) antenatally is rare, and most of these cases are diagnosed in the neonatal period. The defects range from easily treated minor anomalies with good prognosis to those that are difficult and complex. The associated anomalies in these malformations are important determinants for the prognosis and outcome of these cases. Material and methods  The present study was carried out in the department of pediatric surgery in a tertiary care institute. Patients presenting with ARMs in the neonatal period, those reported for definitive surgery, and patients for colostomy closure surgery were included. Patients who died before surgical treatment were excluded from the study. Convenience sampling of 100 patients who met the inclusion criteria was performed until the sample size was reached. Results Out of 63 cases of high variety, 84.12% were males and 15.87% were females. Out of 37 patients of low variety, 43.24% were males and 56.75% were females. The anomalies of the urogenital system were present in 22 (34.92%) out of 63 cases of high ARMs and 10 (27.02%) out of 37 cases of low ARMs. In the male patients, anocutaneous fistula was in 16 (23.18%) of cases. Out of 31 females in the present study, anorectal agenesis with anovestibular fistula was seen in 19 (61.29%) cases. In the early complications, significant bleeding and urethral injury were seen in one (2.63%) patient each. However, among the late complications, anal stenosis, mucosal prolapse, and wound infection were seen in seven (18.42%), five (13.15%), and four (10.52%) patients, respectively. Conclusion  A holistic approach to the management of ARMs is needed with a long-term goal of achieving urinary and fecal continence with good quality of life. The outcome of surgery is dependent on the specific type of malformation, but the results are better when intervention is done early.

Prediction of anorectal malformations with bladder-neck/urethral-prostatic fistula using classification and regression tree analysis

BACKGROUND

The anorectal malformations (ARMs) with bladder-neck/urethral-prostatic fistula in males are the most complex groups in ARMs. It is essential to diagnose them effectively before the primary operation for both surgical modalities and future functional prognosis can be quite different from other types. Our study aimed to develop a classification and regression tree (CART) model for the prediction of ARMs with bladder-neck/urethral-prostatic fistula.

METHODS

A total of 132 newborns with ARMs were included retrospectively and randomly assigned to the training sample and test sample in a 3:1 ratio. The pouch-perineum distance of ultrasound (PPDU), the pouch-perineum distance of invertogram (PPDI), and the rectum gas above the coccyx (RGAC) on the invertogram were hypothesized can serve as individual predictors. The CART analysis was used to determine the best combination of candidate predictors. The model's performance was assessed by the area under the receiver operating characteristic curve (AUC) and validated in the test sample.

RESULTS

All three individual predictors were included in the CART model to predict the ARMs with bladder-neck/urethral-prostatic fistula in the derivation cohort with the following test characteristics (95% CI): sensitivity 75.6% (60.1 to 86.6); specificity 88.9% (76.7 to 95.4); AUC 0.909 (0.854 to 0.965). The model's predicted accuracy was validated in the test cohort (AUC = 0.883). In all 132 subjects, the AUC of the tree model was significantly superior to that of the best individual index: PPDU (0.901 vs. 0.819; p = 0.005).

CONCLUSIONS

A predictive model that consists of PPDU, PPDI, and RGAC may be useful in predicting ARMs with bladder-neck/urethral-prostatic fistula.

Sexual function and fertility of adult males with anorectal malformations or Hirschsprung disease

PURPOSE

The long-term impact of anorectal malformations (ARM) and Hirschsprung disease (HD) on sexual function is well recognized but understudied. This study evaluated self-reported sexual and fertility outcomes in adult males with ARM and HD.

METHODS

This was an IRB approved, prospective study of males in the Adult Colorectal Research Registry who completed surveys between October 2019 and March 2022. Electronic surveys were administered after consenting to being contacted for research. Patients completed the International Index of Erectile Function (IIEF) questionnaire and provided information on fertility outcomes.

RESULTS

Sixty-five patients completed outcome questionnaires: 11 (16.9%) had HD and 54 (83.1%) had an ARM. Nineteen patients reported some degree of erectile dysfunction per IIEF criteria, a greater proportion of whom have ARM (p = 0.046). Twenty (30.7%) have reported having children; there were no differences in rates between HD and ARM patients. Most patients had not attempted to conceive, but eight patients, all of whom have ARM, have pursued fertility investigation or treatments.

CONCLUSION

More patients with ARM reported some degree of erectile dysfunction compared to those with HD. Additionally, some have required fertility treatments. Further investigation is warranted to ensure true low rates of sexual and fertility dysfunction in patients with HD.

Comparing 30-day outcomes between early versus delayed repair of anorectal malformations with perineal or rectovestibular fistulas: An analysis of the ACS NSQIP-Pediatric database

BACKGROUND

Anorectal malformations (ARMs) have a wide spectrum of presentation ranging from mild defects with perineal fistulas to more severe defects requiring complex management. A primary repair of ARMs with perineal or rectovestibular fistulas has been shown to have good outcomes. However, the timing of the reconstruction is still debated. The aim of this study is to investigate the safety of early versus delayed repair.

METHODS

This study was performed using data from the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) from 2012 to 2017. Patients who underwent repair of anorectal malformation with perineal or vestibular fistula were included in the study. Patients with associated diagnosis for Hirschsprung disease, cloaca, rectal prolapse or stenosis, bladder exstrophy, and tracheoesophageal fistula were excluded. 30-day postoperative outcomes included wound and nonwound complications, readmissions, and reoperations. Outcomes were compared by early (≤7 days of age) versus delayed repair (6 weeks to 8 months).

RESULTS

A total of 291 patients were included, with 66 in the early and 231 in the delayed group. Patients in the early group were more likely to be male (68.2% vs 31.8%; p < 0.01) and have cardiac risk factors (71.2% vs 49.4%, p < 0.01). The mean operative time was significantly shorter in the early group (90.1 vs 129.6 min; p < 0.01). 30-day complications were not statistically significant between the two groups (p = 0.76). After multivariate analysis, timing of repair did not affect 30-day complications (p = 0.15).

CONCLUSION

Our study shows that early repair of low anorectal malformations with a perineal or vestibular fistula appears to be associated with no increase in risk of postoperative complications as compared to delayed repair. At present, the decision remains dependent on the surgeon's experience and judgment.

LEVEL OF EVIDENCE

Level III. Retrospective comparative study.

Relationship Between Quality of Life and Social Support in Parents of Children with Congenital Anorectal Malformations in China

PURPOSE

This study aimed to explore the quality of life (QOL) and social support of parents of children with congenital anorectal malformation (ARM), and to examine the relationship between them.

DESIGN AND METHODS

A cross-sectional study was conducted at Anhui Provincial Children's Hospital of China from January to June of 2018. A total of 108 parents participated in this survey. QOL and social support were accessed using the short version of the World Health Organization's Quality of Life Instrument (WHOQOL-BREF) and the Social Support Rate Scale (SSRS), respectively. Analyses were performed with multivariate linear regression and canonical correlation.

RESULTS

The parents' scores in the physical, psychological, and environmental domains were lower than those in the general population in China. Gender, monthly income, combined malformation, objective support, subjective support and utilization of support were the major influencing factors of QOL. A canonical correlation analysis indicated social support was positively correlated with QOL, and subjective support, psychological domain had the largest standardized factor loading in social support and QOL.

CONCLUSIONS

The QOL of parents of ARM patients was not optimistic. More attention needs to be paid to increasing social support for the parents of ARM to enhance their QOL.

PRACTICE IMPLICATIONS

For government, increasing funds and resources to invest in the establishment and improvement of the social support network is necessary. For doctors and nurses, providing better medical and psychological services to patients and their parents is essential.

General complications after surgery for anorectal malformations

The introduction of posterior sagittal anorectoplasty (PSARP) by deVries and Peña in the early 80s has impacted to the treatment of patients with anorectal malformations (ARM). It gained great recognition worldwide in a very short time, and since then, surgeons dealing with the treatment of this complex malformation could achieve tremendous progress in contemporary management of this anomaly. Despite the growing experience and body of information globally, the treatment of ARMs continues to be a challenge to the pediatric surgeons due to the nature and the variability of the anomaly, and short- and long-term problems continue to exist even after nearly 40 years of the PSARP era. Today, knowing more about it, pediatric surgeons are committed to do more for their ARM patients to have them as physically and socially healthy individuals.

Megarectosigmoid in anorectal malformations: the role of laparoscopic resection

Surgical treatment for anorectal malformations may lead to chronic constipation or stool incontinence. The first condition is mostly linked to an abnormal dilation of rectum and sigma and it is primarily managed with medical therapy (laxatives, diet and enemas). When medical therapy fails to improve the symptoms, a surgical resection of the dilated colon is advocated. When performing the procedure it is mandatory to consider all the previous operations the patient undergone. We present a laparoscopic left emicolectomy for an extremely dilated megarectosimoid after posterior sagittal anorectoplasty in childhood for a recto-urethral fistula.

First trimester expression of anorectal malformation: Case report and review of the literature

A 26-years-old woman, underwent an ultrasound examination at 13.4 weeks. A cystic structure was identified in the right lower abdomen. Gradually, the cystic mass was replaced by echogenic content and eventually attained the appearance of hyperechoic bowel. At 21.2 weeks, the anal sphincter could not be demonstrated which was consistent with the diagnosis of isolated anal agenesis. Amniocentesis revealed 46XY karyotype with normal comparative genomic hybridization. After termination of pregnancy at 23 weeks, an autopsy revealed an isolated high type anorectal malformation (ARM) without fistula. We reviewed all 14 cases reported in the literature of first trimester sonographic expression of ARM.

Long-term bowel function, quality of life and sexual function in patients with anorectal malformations treated during the PSARP era

Anorectal malformations are an important group of congenital anomalies that vary widely in their anatomical characteristics and complexity. Understanding the long-term functional outcomes after modern treatments, and how these compare to the general population, are essential for ensuring that patients receive optimal, evidence-based care. With increasing appreciation of the wider impact of the illness on patients and their families, minimizing social disability from fecal incontinence and enabling normal social integration from the outset are key management concerns. This review summarizes the current knowledge on the functional outcomes by type of malformation, reflecting on the literature, and our institutional experience over a follow-up period of nearly 30 years.

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.

Spinal cord anomalies in patients with anorectal malformations without severe sacral abnormalities or meningomyelocele: outcomes after expectant, conservative management

OBJECTIVE The goal of this study was to determine the significance of spinal cord anomalies (SCAs) in patients with anorectal malformations (ARMs) by comparing the outcomes for bowel function, lower urinary tract symptoms (LUTS), and lower-limb neurological abnormalities to these outcomes in patients with similar ARMs and a normal spinal cord. METHODS The spinal cord MRI records of female patients treated for vestibular and perineal fistula (VF/PF) and male patients with rectourethral fistula (RUF) at a single center between 1983 and 2006 were reviewed. Bowel function and LUTS were assessed by questionnaire. Patients with extensive sacral anomalies or meningomyelocele were excluded. RESULTS Of 89 patients (median age 15 years, range 5-29 years), MRI was available in 90% (n = 80; 40 male patients with RUF), and 80% of patients returned the questionnaire (n = 64; 31 male patients with RUF). Spinal cord anomalies were found in 34%, comprising a filum terminale lipoma in 30%, low conus medullaris in 10%, and thoracolumbar syrinx in 6%. Bowel functional outcomes between patients with SCAs (n = 23) and those with a normal spinal cord (n = 41) were not significantly different for soiling (70% vs 63%), fecal accidents (43% vs 34%), and constipation (57% vs 39%; p = not significant for all). The LUTS, including urge (65% vs 54%), urge incontinence (39% vs 24%), stress incontinence (17% vs 22%), and straining (32% vs 29%) were also comparable between groups (p = not significant for all). No patients developed lower-limb neurological abnormalities. CONCLUSIONS The results suggest that the long-term functional outcomes for patients with SCAs who had VF/PF and RUF may not differ significantly from patients with the same type of ARMs and a normal spinal cord. The results favor a conservative approach to their management in the absence of abnormal neurological findings in the lower limbs.

Development of an operative suspension system for the performance of MRI-OR-guided laparoscopic anoplasty

BACKGROUND

MRI-guided laparoscopic assisted anorectoplasty (MRI-LAARP), a new approach for surgical correction of high imperforate anus, does not bisect the sphincter complex as in the PSARP and is able to pull the neorectum through the entire sphincter complex unlike the LAARP. There is no available MRI-compatible device to position and transport patients during this procedure. We report on the design of such a device here.

METHODS AND DEVICE

The device was constructed from 1.0″ polyvinylchloride tubing and poly-methyl methacrylate (Plexiglass(®)) platform. The device has a stable, rigid base on which platform is secure. An adjustable and removable superstructure is secured to this base to suspend legs for lithotomy position.

RESULTS

MRI-LAARP has been performed on 6 patients. The device has performed well and meets requirements set forth in development including construction with MRI-compatible materials, size fitting in the MRI bore, ability to hold patient in lithotomy position, ability to position and support MRI flex coils, and providing stability while transporting to a separate OR with needle in position.

CONCLUSIONS

This device provides a stable structure to position and transport a patient with a needle in a tenuous position without dislodgement allowing this procedure, and potentially other procedures, to be done in hospitals without MROR capability.

Children With Anorectal Malformations, Hirschsprung Disease, and Their Siblings: Proxy Reports and Self-Reports

OBJECTIVES

The aim of the present study was to compare parent proxy reports with that of self-reports of children with anorectal malformations (ARMs) or Hirschsprung disease (HD) and healthy siblings and thereafter was examine whether these comparisons differed between patients and their siblings.

METHODS

Parents (n = 98) of either children with ARM (n = 44) or HD (n = 54) and a healthy sibling (n = 98) recruited from the 6 Dutch pediatric surgical centers and from the ARM and HD patient societies were included in this cross-sectional multilevel study. Agreement between child self-reports and parent proxy reports was compared through mean differences and through (intraclass) correlations. We conducted multilevel analyses to take dependencies between assessments within families into account.

RESULTS

All of the children (children with ARM or HD and their siblings) reported more pain and symptoms than their parents reported. We also found that only children with ARM or HD reported less positive emotions than their parents. Furthermore, higher correlations were found between parent proxy reports and patient-self reports than between parent proxy reports and sibling self-reports on cognitive functioning and social interaction.

CONCLUSIONS

Parents tend to overestimate the physical functioning of both their ill and healthy children, and overestimate the emotional functioning of only their children with ARM or HD. Furthermore, children with ARM or HD and parents agree more on health-related quality of life domains than healthy children and parents.

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.

Loop versus divided colostomy for the management of anorectal malformations

PURPOSE

The purpose of this study was to compare the clinical outcomes of loop and divided colostomies in patients with anorectal malformations (ARM).

METHODS

We performed a retrospective cohort study reviewing the medical records of all patients with ARM managed with diverting colostomies between 2000 and 2010 at our institution. Independent variables and outcomes of stoma complications were analyzed by parametric measures and logistic regression.

RESULTS

One hundred forty-four patients managed with a colostomy for ARM were evaluated (37.5% females, 50.7% loop, 49.3% divided). The incidence of patients with loop and divided colostomies who developed stoma-related complications was 31.5 and 15.5%, respectively (p=0.031). The incidence of prolapse was 17.8 and 2.8%, respectively (p=0.005). Multivariable-logistic regression controlling for other significant independent variables found loop colostomies to be positively associated with the development of a stoma complication (OR 3.13, 95%CI (1.09, 8.96), p=0.033). When individual complications were evaluated, it was only stoma prolapse that was more likely in patients with loop colostomies (OR 8.75, 95%CI (1.74, 44.16), p=0.009).

CONCLUSION

Because of the higher incidence of prolapse, loop colostomies were found to be associated with a higher total incidence of complications than divided stomas. The development of other complications, including urinary tract infections (UTIs) and megarectum, were independent of the type of colostomy performed.