Loop versus divided colostomy for the management of anorectal malformations

Classification and Surgical Management of Anorectal Malformations: A Systematic Review and Evidence-based Guideline From the APSA Outcomes and Evidence-based Practice Committee

OBJECTIVE

Treatment of neonates with anorectal malformations (ARMs) can be challenging due to variability in anatomic definitions, multiple approaches to surgical management, and heterogeneity of reported outcomes. The purpose of this systematic review is to summarize existing evidence, identify treatment controversies, and provide guidelines for perioperative care.

METHODS

The American Pediatric Surgical Association Outcomes and Evidence Based Practice Committee (OEBP) drafted five consensus-based questions regarding management of children with ARMs. These questions were related to categorization of ARMs and optimal methods and timing of surgical management. A comprehensive search strategy was performed, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to perform the systematic review to attempt to answer five questions related to surgical care of ARM.

RESULTS

A total of 10,843 publications were reviewed, of which 90 were included in final recommendations, and some publications addressed more than one question (question: 1 n = 6, 2 n = 63, n = 15, 4 n = 44). Studies contained largely heterogenous groups of ARMs, making direct comparison for each subtype challenging and therefore, no specific recommendation for optimal surgical approach based on outcomes can be made. Both loop and divided colostomy may be acceptable methods of fecal diversion for patients with a diagnosis of anorectal malformation, however, loop colostomies have higher rates of prolapse in the literature reviewed. In terms of timing of repair, there did not appear to be significant differences in outcomes between early and late repair groups. Clear and uniform definitions are needed in order to ensure similar populations of patients are compared moving forward. Recommendations are provided based primarily on A-D levels of evidence.

CONCLUSIONS

Evidence-based best practices for ARMs are lacking for many aspects of care. Multi-institutional registries have made progress to address some of these gaps. Further prospective and comparative studies are needed to improve care and provide consensus guidelines for this complex patient population.

LEVEL OF EVIDENCE: 3

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.

Classic divided sigmoidostomy vs loop sigmoidostomy in anorectal malformations: time for change?

PURPOSE

Divided sigmoidostomy (DS) is the classic stoma for patients with anorectal malformations (ARM). Loop sigmoidostomies (LS) in ARM are associated with a higher risk of stoma prolapse and urinary tract infections (UTI). This is not clearly supported by literature. We compared our experience with both techniques.

METHODS

Retrospective study of ARM patients who underwent DS or LS between 2013 and 2023. We analysed demographics, associated malformations, intraoperative variables, oral intake and stoma functioning times, hospital stay, complications, prolapses, and UTI.

RESULTS

Of 40 patients, 29 underwent open DS and 11 laparoscopic LS. Demographics, malformation type, associated anomalies, surgical time, intraoperative and anaesthetic complications were comparable. Postoperative complications were higher in DS than LS [14(48.3%) vs 1(9.1%), (p = 0.02)], mostly due to wound complications [12(41.3%) vs 0(0%), (p = 0.01)]; with 3 dehiscenses and 3 strictures reintervened. The hours to oral intake and stoma functioning were higher for DS [48(39-90) and 48(24-48) vs 24(24-48) and 24(24-24), (p < 0.05)], with more days of hospital stay [36(19-60) vs 8(5-10), (p = 0.001)]. Prolapses [1(3.4%) vs 1(9.1%)] and UTIs [3(10.3%) vs 1(9.1%) (p > 0.05)] were comparable.

CONCLUSION

LS in ARM patients have no higher risk of prolapse or UTI than DS. DS had more complications, mostly wound infections, strictures and dehiscenses.

The Association of Weight With Surgical Morbidity in Infants Undergoing Enterostomy Reversal: A Study of the NSQIP-Pediatrics Database

INTRODUCTION

Optimal criteria and timing for enterostomy closure (EC) in neonates is largely based on clinical progression and adequate weight, with most institutions using 2.0-2.5 kg as the minimum acceptable weight. It is unclear how the current weight cutoff affects post-operative morbidity.

AIM

To determine how infant weight at the time of EC influences 30-day complications.

METHODS

Infants weighing ≤4000 g who underwent EC were identified in the 2012-2019 ACS NSQIP-P database. Demographics, comorbidities, and 30-day outcomes were assessed using univariate analysis. Multivariable logistic regression controlling for ASA score, nutritional support, and ventilator support was used to estimate the independent association of weight on risk of 30-day complications.

RESULTS

A total of 1692 neonates from the NSQIP-P database during the years 2012-2019 met inclusion criteria. Neonates weighing <2.5 kg were significantly more likely to have a younger gestational age, require ventilator support, and have concurrent comorbidities. Major morbidity, a composite outcome of the individual postoperative complications, was observed in 283 (16.7%) infants. ASA classifications 4 and 5, dependence on nutritional support, and ventilator support were independently associated with increased risk of 30-day complications. With respect to weight, we found no significant difference in major morbidity between infants weighing <2.5 kg and infants weighing ≥2.5 kg.

CONCLUSION

Despite using a robust, national dataset, we could find no evidence that a defined weight cut-off was associated with a reduction in major morbidity, indicating that weight should not be a priority factor when determining eligibility for neonatal EC.

LEVEL OF EVIDENCE

III.

Anorectal Malformation Patients in Australia and Europe: Different Location, Same Problem? A Retrospective Comparative Registry-based Study

Anorectal malformations (ARM) encompass a spectrum of rare congenital defects of the rectum and anus, requiring specialized reconstructive surgery. To improve epidemiological and clinical research in rare diseases such as ARM, collaborative efforts and patient registries are key. This retrospective study pools clinical data over a 30-year period from two ARM patient registries (The Royal Children's Hospital (RCH) in Melbourne, Australia, and the ARM-Network Consortium in Europe). It aims to draw comparisons on demographics, management, and outcomes between ARM patients in Australia and Europe. A total of 2947 ARM patients were included in the analyses. The RCH cohort had more complex ARM types (including rectal atresia and recto-vaginal fistula) and more associated anomalies, specifically skeletal, cardiac, and/or trachea-esophageal, than ARM-Net patients. Other patient characteristics were similar. Treatments clearly differed between the groups. European surgeons favoured the PSARP approach for both less complex and more complex ARM types, where Australian surgeons opted more often for cutback surgery in less complex, and laparoscopic assistance in more complex types. Complications were differently distributed, with less complications after LAARP and more after PSARP at RCH, compared to ARM-Net. While RCH patients more often required a redo, ARM-Net patients more commonly underwent anal dilatations. Anorectal malformation patients in Australia and Europe had minor differences in disease characteristics, and both operative and medical approaches differed. Joint efforts such as the present study emphasize the importance of collaboration to elucidate areas of improvement where surgeons may learn from each other across the world, ultimately improving patient outcomes. TYPE OF STUDY: Original Research. LEVEL OF EVIDENCE: III.

Clinical application of middle descending colon-double lumen ostomy with distal stoma narrowing in the treatment of anorectal malformation

BACKGROUND

Anorectal malformations (ARMs) are the most common congenital anomaly of the digestive tract. And colostomy should be performed as the first-stage procedure in neonates diagnosed with intermediate- or high-type ARMs. However, the most classic Pe˜na's colostomy still has some disadvantages such as complicated operation procedure, susceptibility to infection, a greater possibility of postoperative incision dehiscence, difficulty of nursing and large surgical trauma and incision scarring when closing the stoma. We aimed to explore the effectiveness of middle descending colon-double lumen ostomy (MDCDLO) in the treatment of high and intermediate types of anorectal malformations.

METHODS

We retrospectively reviewed the data of patients who underwent MDCDLO for high or intermediate types of ARMs between June 2016 and December 2021 in our hospital. The basic characteristics were recorded. All patients were followed up monthly to determine if any complication happen.

RESULTS

There were 17 boys and 6 girls diagnosed with high or intermediate types of ARMs in our hospital between June 2016 and December 2021. All 23 patients were cured without complications such as abdominal incision infection, stoma stenosis, incisional hernia, and urinary tract infection in the postoperative follow-up time of 6 months to 6 years except one case of proximal intestinal prolapse was restored under anesthesia.

CONCLUSION

MDCDLO offers the advantages of simplicity, efficiency, safety, mild trauma, and small scarring in the treatment of high and intermediate types of anorectal malformations.

Five Years' Single-center Experience of a Modified Approach to Divided Sigmoid Colostomy for Anorectal Malformation

BACKGROUND

In patients with anorectal malformation (ARM), a divided descending colostomy is associated with high complication rates, including wound infection, dehiscence, and prolapse, and it places a significant burden on caregivers. To decrease the chances of such complications, we modified our approach for colostomy fashioning by keeping an intact skin bridge between the colostomy and mucous fistula. The objective was to compare the rate of complications among patients diagnosed with ARM who underwent a modified divided descending colostomy and classical descending colostomy.

METHODS

We included all the patients diagnosed with ARM who underwent a divided colostomy with modified (group A) or classical technique (group B) in the last 5 years. The type of approach used to fashion the stoma was based on the surgeon's preference than on patients' selection criteria. All patients were followed and monitored for postoperative complications. SPSS version 26 was used to analyze the data.

RESULTS

A total of 62 patients with ARM underwent the colostomy creation; 27 in group A and 35 in group B. Males were more in both groups and other demographic variables were comparable. The most common associated anomalies were cardiac (58%). The mean duration of surgery was 72.2 ± 18.26 min in group A while 91.25 ± 21.43 min in group B (P = 0.000). The mean hospital stay was 4.28 ± 3.63 days in group A while 7.97 ± 6.12 days in group B (P = 0.007). The overall complication rate was 14.8% in group A and 34.2% in group B (P = 0.082).

CONCLUSION

The modified approach to fashioning a divided colostomy is easily reproducible and carries a low risk of postoperative complications.

LEVEL OF EVIDENCE

IV.

Fetal and Newborn Management of Cloacal Malformations

Cloaca is a rare, complex malformation encompassing the genitourinary and anorectal tract of the female in which these tracts fail to separate in utero, resulting in a single perineal orifice. Prenatal sonography detects a few cases with findings such as renal and urinary tract malformations, intraluminal calcifications, dilated bowel, ambiguous genitalia, a cystic pelvic mass, or identification of other associated anomalies prompting further imaging. Multi-disciplinary collaboration between neonatology, pediatric surgery, urology, and gynecology is paramount to achieving safe outcomes. Perinatal evaluation and management may include treatment of cardiopulmonary and renal anomalies, administration of prophylactic antibiotics, ensuring egress of urine and evaluation of hydronephrosis, drainage of a hydrocolpos, and creation of a colostomy for stool diversion. Additional imaging of the spinal cord and sacrum are obtained to plan possible neurosurgical intervention as well as prognostication of future bladder and bowel control. Endoscopic evaluation and cloacagram, followed by primary reconstruction, are performed by a multidisciplinary team outside of the neonatal period. Long-term multidisciplinary follow-up is essential given the increased rates of renal disease, neuropathic bladder, tethered cord syndrome, and stooling issues. Patients and families will also require support through the functional and psychosocial changes in puberty, adolescence, and young adulthood.

Vesicoureteral reflux increases the risk of urinary tract infection prior to corrective surgery in newborn males with anorectal malformation

PURPOSE

The ideal colostomy type indicated for patients with anorectal malformation (ARM) is disputed. The aim of this study was to analyze the clinical factors associated with urinary tract infection (UTI) prior to corrective surgery in male ARM without perineal fistula having undergone diverting enterostomy.

METHODS

A retrospective review of patients diagnosed with ARM and surgically managed at our center from January 2011 to December 2019 was performed. Logistic regression was used to analyze the association between clinical factors and UTI.

RESULTS

Eighty boys with ARM without perineal fistula underwent diverting enterostomy and subsequent corrective surgery via laparoscopic-assisted anorectal pull-through. A sigmoid loop colostomy was most often performed (70 patients, 87.5%). Twenty-nine patients (36.3%) were diagnosed with vesicoureteral reflux (VUR), including 14 (48.3%) with febrile UTIs. Six patients had other concomitant genitourinary anomalies excluding VUR. Multivariate logistic regression analysis revealed the presence of VUR as the only independent factor associated with the occurrence of febrile UTI (OR 17.3, 95% CI 3.51-85.26, p < 0.001).

CONCLUSION

The development of UTI in newborn males with ARM is associated with the presence of VUR, regardless of stoma type. Voiding cystourethrography should be considered in patients with ARM for early diagnosis of VUR and subsequent antibiotic prophylaxis.

Outcomes after enterostomies in children with and without motility disorders: A description and comparison of postoperative complications

PURPOSE

To provide an overview of complications after ileostomy or colostomy procedures in children, and to compare outcomes between patients with gastrointestinal motility disorders (i.e. functional constipation, Hirschsprung's disease, pediatric intestinal pseudo-obstruction (PIPO)) and children without motility disorders (including necrotizing enterocolitis, anorectal malformation and inflammatory bowel disease).

METHODS

We performed a retrospective study of children who underwent an enterostomy procedure at our institution. The number and type of complications and subsequent reoperations after ostomy formation were determined. Complications were scored using the Clavien-Dindo classification. A complication of ≥ grade III-b was considered a high-grade complication.

RESULTS

129 children with an ileostomy and 61 children with a colostomy were included. Of these, 62 children (32.6%) had motility disorders; functional constipation (n=40), Hirschsprung's disease (n=18) and PIPO (n=4). The total prevalence of complications was 73.2%. Comparing the perioperative data, children with motility disorders significantly more often underwent a laparoscopic procedure (59.7% vs. 10.9%, p=0.000) and had an end stoma-configuration (37.1% vs. 14.1%, p=0.000) as compared to children without motility disorders. Children with motility problems had a higher complication rate (88.7% vs. 65.5%, OR 4.1, 95% CI 1.7-9.8, p=0.001) compared to children without motility problems, and a larger proportion of complications was classified as high-grade complications (61.8% vs. 31.0% p =0.002).

CONCLUSION

A high complication rate after enterostomy formation was detected. Children with gastrointestinal motility disorders had more and more severe complications as compared to children without motility disorders.

LEVEL OF EVIDENCE

Level III TYPE OF STUDY: Retrospective comparative study.

Risk Factors for Adverse Outcomes after Ostomy Reversal in Infants Less than Six Months Old

The purpose of this study was to determine risk factors for 30-day complications, reoperation, and readmission after ostomy reversal in infants less than six months old. Infants aged two weeks to six months who underwent ostomy reversal were identified in the 2012 to 2016 ACS NSQIP Pediatric database. Demographics, comorbidities, and 30-day outcomes were assessed. Multivariable logistic regression was used to estimate the independent effects of clinical variables on risk of 30-day complications, reoperation, and readmission. Among 1021 infants, 163 (16%) suffered a 30-day complication. SSIs were the most common complication (5.7%), followed by unplanned reintubation (5.2%) and bleeding (3%). Mortality was 0.4 per cent. Dependence on nutritional support and hematologic disorders were independently associated with postoperative complications. Forty-five children (4.4%) required reoperation and 22 (2.2%) were readmitted for conditions related to the procedure. Younger age and preoperative dependence on oxygen or nutritional support were associated with increased length of stay. SSI, unplanned reintubation, and bleeding are the most frequent complications after ostomy takedown in infants less than six months old. Attention to risk factors predisposing to these complications, including dependence on nutritional support and hematologic disorders, may contribute to improved surgical outcomes.

Caracterização de crianças e adolescentes com estomas em um serviço de saúde

Objetivo: Caracterizar o perfil socioeconômico e clínico de crianças e adolescentes com estomias atendidos em um hospital público de referência em saúde infantil do estado do Piauí, Brasil. Métodos: Estudo descritivo, transversal, realizado com 55 crianças/adolescentes, com pelo menos uma estomia. Resultados: Houve predomínio do sexo masculino, cor parda, média de idade de 4,1anos. As principais causas para confecção da estomia foram malformações congênitas, destacando-se a anomalia. Com relação ao sistema orgânico, o gastrintestinal foi o mais acometido e a colostomia foi a mais frequente. A maioria dos participantes com estomias de eliminação não utilizava equipamento coletor. Com relação às complicações da estomia, a saída acidental da sonda de gastrostomia foi a mais comum, seguida de sangramento da estomia. A dermatite foi a complicação da pele mais comum. Conclusão: A realização deste estudo possibilitou conhecer o perfil sociodemográfico de crianças e adolescentes com estomia e promover reflexões acerca do cuidado de enfermagem para a melhoria da assistência prestada a essa clientela.

Characterization of children and teenagers with ostomies in a health service

Objective: To characterize the socioeconomic and clinical profile of children and adolescents with ostomies attended at a public reference hospital in children’s health in the state of Piauí, Brazil. Methods: Descriptive cross-sectional study of 55 children/adolescents with at least one ostomy. Results: There was a predominance of males, brown, mean age of 4.1 years. The main causes for the confection of the stoma were congenital malformations, especially the anomaly. Regarding the organic system, the gastrointestinal was the most affected and the colostomy was the most frequent. The majority of participants with elimination ostomies did not use collecting equipment. With regard to the complications of the stoma, the accidental release of the gastrostomy tube was the most common, followed by stomatal bleeding. Dermatitis was the most common skin complication. Conclusion: The realization of this study made it possible to know the socio-demographic profile of children and teenagers with ostomies and to promote reflections about nursing care to improve the assistance provided to these clients.

Loop colostomies are safe in anorectal malformations

AIM OF THE STUDY

Divided colostomy (DC) has been recommended in anorectal malformations (ARMs) with previously reported advantages of decreasing overflow into the distal limb and urinary tract infections (UTIs). Skin bridge loop colostomy (LC) is a technically easier alternative without an increase in these complications. We report our institutional experience of LC in ARM.

METHODS

Retrospective study (Institution-approved Clinical Audit) reviewing the clinical records of all patients with ARM undergoing stoma formation in a single UK tertiary pediatric surgical center (2000-2015). Data collected included type of ARM, associated anomalies, type and level of colostomy, time to stoma closure, complications and UTIs.

RESULTS

One hundred and eighty-two (95 female) patients underwent colostomy formation for ARM. The vast majority (171/ 94%) underwent LC; 9 (5%) had a divided colostomy (DC) and 2 (1%) had no available data. The spectrum of defects in girls included rectovestibular (62/65%), rectovaginal (4/4%) and cloaca (29/31%). In boys, 71 (82%) had a fistula to the urinary tract and 16 (18%) presented with a perineal fistula. Urological abnormalities coexisted in 87 (47.8%) patients. Thirty five (21%) patients developed UTIs. Among the 19 girls who developed UTI, 8 had rectovestibular fistula and 11 had cloaca. Of the 16 boys who developed UTI, 14 had a fistula to the urinary tract and 11 had an independent urological abnormality. The mean time from stoma formation to stoma closure was 10 (3-52) months. Complications were reported in 22 (12%) LCs. Fifteen patients (9%) developed a stoma prolapse following LC with 10 (6%) requiring surgical revision.

CONCLUSIONS

This is the largest reported series of outcomes following LC for ARM. LC is easier to perform and to close, requiring minimal surgical access, with comparable complications and outcomes to those published for DC.

TYPE OF STUDY

Retrospective comparative study.

LEVEL OF EVIDENCE

III.

Single-stage repair of rectoperineal and rectovestibular fistulae can be safely delayed beyond the neonatal period

PURPOSE

We sought to examine the short-term outcomes following single-stage repair of rectoperineal and rectovestibular fistulae in infants and identify risk factors for wound complication.

METHODS

Patients with a rectoperineal or rectovestibular fistula treated with a single-stage repair beyond the neonatal period (>30days of age) at a pediatric colorectal center (2011-2016) were reviewed.

RESULTS

36 patients with a rectoperineal and 7 patients with a rectovestibular fistula were repaired using the Posterior Sagittal Anorectoplasty (PSARP) approach. Median follow-up was 31months. The median age and weight at the time of repair were 166days and 6.5kg. Four patients (11%) suffered a wound complication (3 rectoperineal, 1 rectovestibular). Two required a diverting colostomy to allow wound healing. Two patients suffered skin separation managed with local wound care. All 4 patients experienced satisfactory wound healing without anoplasty stricture. Two different patients developed a stricture of the neo-anus. Age and weight at time of repair, gender, and presence of a genitourinary anomaly were not associated with wound complications.

CONCLUSION

Delayed single-stage repair of rectoperineal and rectovestibular fistulae can be performed safely in infants beyond the newborn period. With attentive treatment, satisfactory healing can be anticipated if a wound complication is encountered.

LEVEL OF EVIDENCE

Retrospective Comparative Study, Level III.

Impact of relationship between the stoma site and the primary incision on occurrence of laparotomy wound infection in contaminated or dirty wound operations in neonates

BACKGROUND

In neonatal surgical patients requiring an enterostomy, there is no definitive recommendation regarding the ideal enterostomy location: at the edge of the primary incision or at a different incision.

METHODS

We retrospectively reviewed 2005-2017 administration data in our institution. All neonatal patients who underwent contaminated or dirty wound laparotomy and enterostomy construction were evaluated regarding the enterostomy location, occurrence of postoperative incisional surgical-site infection (SSI) at the primary incision, and stoma-related complications.

RESULTS

Patients were divided into two groups based on stoma location: at the primary incision (the same incision group: SI group, n = 16) or at another incision (different incision group: DI group, n = 23). We performed 2 jejunostomies, 13 ileostomies, and 1 colostomy in the SI group, and 4 jejunostomies, 18 ileostomies, and 1 colostomy in the DI group. One of 16 patients (6.3%) in the SI group and 2/23 patients (8.7%) in the DI group experienced superficial incisional SSI, with comparable SSI incidence between groups (p = 0.78). Every SSI did not result in stoma-related complications.

CONCLUSIONS

Although the enterostomy location did not influence the incidence of laparotomy wound infection in this study, prospective studies are mandatory to fully assess the safety of enterostomy construction at the edge of the primary incision.

Minimally Invasive Surgery in the Management of Anorectal Malformations

Imperforate anus, a variant of anorectal malformation (ARM), is a common congenital anomaly requiring surgical attention in the newborn period. It may present with a variety of anatomic configurations, largely dependent on the presence and location of a fistula. The location (or characteristics) of a fistula, which usually lies between the gastrointestinal tract and the genitourinary tract or perineum, is often used in determining the type and timing of operative management. This article discusses the work-up and management, modes of treatment and their postoperative outcomes, and continued controversy regarding the use of minimally invasive surgical approaches to ARM.

Loop versus divided colostomy for the management of anorectal malformations: a systematic review and meta-analysis

BACKGROUND

The ideal colostomy type for patients with anorectal malformations (ARM) is undetermined. We performed a systematic review and meta-analysis of short-term complications comparing loop and divided colostomies.

METHODS

After review registration (PROSPERO: CRD42016036481), multiple databases were searched for comparative studies without language or date restrictions. Gray literature was sought. Complications investigated included stomal prolapse/hernia/retraction, wound infections, and urinary tract infections (UTIs). Two reviewers independently assessed study eligibility and the quality of included studies. Meta-analysis of selected complications was performed using Revman 5.3, with p<0.05 considered significant.

RESULTS

Twenty-six studies were included, and four were multi-institutional. Reporting standards were highly variable. Studies scored between 6 and 9 of possible nine stars on the NOS. Overall, 3866 neonates with ARM were incorporated, in which 2241 loop colostomies and 1994 divided colostomies were reported. Of 10 studies reporting short-term complications, the overall rate was 27%. Meta-analysis demonstrated no significant difference in the incidence of UTIs, (OR: 2.55 [0.76, 8.58], p=0.12), while loop colostomies had a significantly higher prolapse rate (See figure). No publication bias was noted.

CONCLUSIONS

A colostomy for patients with an ARM is a source of considerable morbidity. Divided colostomies reduce the risk of subsequent prolapse and may represent the preferred approach.

LEVEL OF EVIDENCE

3A.

Outcome of loop versus divided colostomy in the management of anorectal malformations

BACKGROUND

Colostomy is a common part of the management of high anorectal malformation (ARM) in the pediatric population.

OBJECTIVE

To evaluate whether the type of colostomy (loop vs divided) has an impact on outcome in patients with ARM.

DESIGN

A retrospective study.

SETTING

King Faisal Specialist Hospital and Research Center, a tertiary care center.

PATIENTS AND METHODS

All patients who were managed with colostomy for ARM and had definitive repair during the period of January 2000 to December 2014. Outcomes relative to the type of the colostomy were compared.

MAIN OUTCOME MEASURES

Morbidities associated with each type of colostomy.

RESULTS

There were 104 patients managed for ARM with colostomy as staged procedures, 63 males and 41 females. Patients had a colostomy at a median age of 6 days and were closed at a median of 11 months. Definitive repair was at a median age of 17 months. Type of fistula was 8 perineal, 21 rectovestibular, 35 rectourethral, 11 rectovesical and there were 16 without fistula and 13 cloaca anomalies. There were 55 loop and 49 divided colostomies. There were 91 descending/sigmoid and 13 transverse colostomies. Operative time for loop colostomy closure was shorter than with divided colo6stomy (76 minutes vs 94 minutes, P=.002). Three patients among the divided group had reversed orientation of the colostomy that had affected bowel preparations negatively prior to its repair. There was no differences in complications of creation and closure of loop and divided colostomies except in occurrence of skin excoriation. There was more skin excoriation with divided colostomy compared to loop colostomy (17 vs 10, P=.04).

CONCLUSIONS

Loop colostomy has a shorter closure operative time and relatively fewer complications compared to the divided colostomy. Our data suggests that loop colostomy may be more favorable than divided colostomy for ARM patients.

LIMITATIONS

Retrospective nature of the study and some colostomies performed at other hospitals.

The morbidity of a divided stoma compared to a loop colostomy in patients with anorectal malformation

PURPOSE

Loop colostomies may contaminate the genitourinary (GU) tract in patients with anorectal malformations (ARM) owing to incomplete diversion of stool. Stoma complications are also thought to be higher with a loop versus divided colostomy. We sought to compare the morbidity, including urinary tract infections (UTI), in these two types of colostomies in children with ARM.

METHODS

A review was performed at a children's hospital (1989-2014). Children with ARM who had a colostomy performed were identified. Demographic data and outcome variables were collected. Analyses included Student's t-test, Fischer's exact and logistic regression as appropriate.

RESULTS

171 patients were identified (loop=78; divided=93). Thirty percent of patients with a divided colostomy and 24% with a loop experienced a stoma complication (p=0.5). A subgroup analysis of children with a rectourinary fistula (54 divided, 26 loop) was performed to assess for effect of colostomy type on UTI. After controlling for other UTI risk factors (major GU anomalies, vesicostomy, and prophylactic antibiotics), loop ostomies were not associated with risk of UTI (OR 0.83, 95% CI 0.27-2.63). No patient with a loop colostomy developed megarectum.

CONCLUSIONS

Children with ARM who undergo a loop colostomy are not at a detectable increased risk of experiencing a UTI compared to a divided stoma. The rate of stoma complication is high regardless of the type of stoma created.

Survey on the management of anorectal malformations (ARM) in European pediatric surgical centers of excellence

PURPOSE

Various management strategies for anorectal malformations (ARM) have been proposed. The aim of this study was to assess the current management in centers of excellence in Europe.

METHODS

An online survey on the pre- and post-operative concepts, surgical techniques, and the management of complications was sent to the representative experts of 28 selected European centers of pediatric surgery with special expertise in the treatment of ARM.

RESULTS

The survey was completed by 25 experts from 14 countries. To assess the level of the rectal pouch in newborns 60% of participants perform a prone cross-table X-ray and 52% ultrasound. If an ostomy is required, 84% create divided Peña stomas. Primary repair in the newborn period is performed in females with rectoperineal (92%), rectovestibular (60%), and no fistula (32%), and in males with rectoperineal (92%), rectourinary (17%) and no fistula (38%). For 68 % of surgeons, the PSARP is the preferred surgical approach for "low" malformations. Laparoscopically assisted pull-throughs are routinely performed by 48% of experts for ARM with bladderneck and 28% for rectoprostatic fistula. 88% perform postoperative dilations.

CONCLUSIONS

The management of ARM in Europe is very heterogeneous. High-quality clinical studies are needed to provide scientific evidence for the optimal treatment strategies.