Anorectal malformations with good prognosis: variables affecting the functional outcome

Bowel function and features of bowel dysfunction in preschool children with anorectal malformation type rectoperineal and rectovestibular fistula

Anorectal malformations (ARMs) of the rectoperineal and rectovestibular fistula type (RPF/RVF) generally have a good prognosis but may be accompanied by bowel dysfunction, especially constipation. Bowel dysfunction in preschoolers may persist into adolescence and adulthood, exerting a negative effect on their quality of life. This study was designed to evaluate bowel function and identify the features of bowel dysfunction in preschoolers with RPF/RVF across type and sex differences. A total of 159 preschoolers with RPF/RVF (male RPF group, n = 95; female RPF group, n = 26; RVF, n = 38) and 128 normal control preschoolers (control group, n = 128; female control group, n = 35), according to the bowel function score (BFS) obtained through a questionnaire survey, the BFS items in the questionnaire, and the clinical characteristics of patients were compared among groups. The rates of bowel dysfunction (BFS < 17) were 27.2% and 50.0% in the RPF and RVF groups, respectively. Normal rates of BFS items, namely, ability to hold back defecation, feels/reports of the urge to defecate, frequency of defecation, and constipation, in the RPF and RVF groups were significantly lower than those in the control and female control groups (all p < 0.05). After subgroup analysis among the male RPF, female RPF, and RVF groups, higher rates of normal bowel function and ability to hold back defecation were found in the male RPF group than in the female RPF and RVF groups (p < 0.05). Normal rates of feels/reports of the urge to defecate were higher in the male and female RPF groups than in the RVF group (all p < 0.05). The rate of never soiling in the male RPF group was significantly higher than that in the RVF group (p < 0.05).  Conclusions: In patients with RPF/RVF, bowel dysfunction is still prevalent, characterized by inadequate ability to hold back defecation, inability to feel/report the urge to defecate, soil, less frequent defecation, and constipation. However, male RPF patients had better overall bowel function than female RPF or RVF patients, including more adequate ability to hold back defecation and feels/reports of the urge to defecate and slighter soiling, which may be linked to early age at surgery, low occurrences of low sacral ratio, and tethered cord in male RPF.  Trial registration: This study was retrospectively registered in ClinicalTrials.gov on 09/01/2023 (NCT05716230). What is Known: • Rectoperineal and rectovestibular fistula (RPF/RVF) of the anorectal malformation (ARM) type has a good prognosis but may cause bowel dysfunction, especially constipation. • Bowel dysfunction at preschool age may lead to social and psychological disorders that undermine the quality of life in adolescence and adulthood. What is New: • Bowel function in preschoolers with RPF/RVF was deeply evaluated in a relatively large number of patients and normal control children. • Features of bowel dysfunction in RPF/RVF preschoolers across type and gender differences were identified in this study.

Can Neonatal Pull-through Replace Staged Pull-through for the Management of Anorectal Malformation? A Systematic Review and Meta-analysis

Anorectal malformations (ARMs) are managed classically in three stages - colostomy at birth, anorectal pull-through after 2-3 months, and stoma closure. Single-stage pull-through has been contemplated in neonatal age aimed to reduce the number of procedures, better long-term continence, the better psycho-social status of the child, and reduced cost of treatment, especially in resource-strained countries. We conducted a systematic review comparing neonatal single-stage pull-through with stage pull-through and did a meta-analysis for the outcome and complications. Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were followed. PubMed and Scopus databases were searched and RevMan 5.4.1 was used for the meta-analysis. Fourteen comparative studies including one randomized controlled trial were included in the systematic review for meta-analysis. The meta-analysis included 1845 patients including 866 neonates undergoing single-stage pull-through. There was no statistically significant difference for the occurrence of surgical site infection (odds ratio [OR] 0.82, 95% confidence interval [CI]: 0.24-2.83), urinary tract injury (OR 1.82, 95% CI: 0.85-3.89), rectal prolapse (OR 0.98, 95% CI: 0.21-5.04), anal stenosis/stricture, voluntary bowel movements (OR 0.97, 95% CI: 0.25-3.73), constipation (OR 1.01, 95% CI: 0.61-1.67), soiling (OR 0.89, 95% CI: 0.52-1.51), mortality (OR 1.19, 95% CI: 0.04-39.74), or other complications. However, continence was seen to be better among patients undergoing neonatal pull-through (OR 1.63, 95% CI: 1.12-2.38). Thus, we can recommend single-stage pull-through for managing patients with ARMs in the neonatal age.

Evaluation of Anal Sphincter with High Resolution Anorectal Manometry and 3D Reconstruction in Patients with Anorectal Malformation

BACKGROUND

Patients with anorectal malformation (ARM) need long-term follow-up, in order to evaluate fecal continence; the main predictors of longer-term success are the type of ARM, associated anomalies and sacral integrity. Three-Dimensional High Resolution Anorectal Manometry (3D-HRAM) gives detailed information on pressure on the anal complex profile. Our objective was to analyze anal sphincter activity in ARM patients with 3D-HRAM establishing the correlation between manometric and clinical data.

METHODS

Forty ARM patients were submitted to 3D-HRAM: manometric, anatomical and clinical scores were correlated with each other and with the bowel management response (BM).

RESULTS

A positive correlation between all scores and types of ARM was found: in high ARM and in patients with spinal anomalies (regardless to ARM type) lower scores were reported and even after BM they did not achieve good continence.

CONCLUSIONS

3D-HRAM gives detailed data on the functional activity of the anal sphincter complex. Our study revealed a correlation between manometric parameters and clinical outcomes, confirming spinal malformations and ARM type as the most important prognostic risk factors for a bad outcome. Specific sphincteric defects can also be explored with manometry, allowing for tailored bowel management strategies.

Post-Operative Anorectal Manometry in Children following Anorectal Malformation Repair: A Systematic Review

Despite surgical correction, children with anorectal malformations may experience long-term bowel dysfunction, including fecal incontinence and/or disorders of evacuation. Anorectal manometry is the most widely used test of anorectal function. Although considerable attention has been devoted to its application in the anorectal malformation cohort, there have been few attempts to consolidate the findings obtained. This systematic review aimed to (1) synthesize and evaluate the existing data regarding anorectal manometry results in children following anorectal malformation repair, and (2) evaluate the manometry protocols utilized, including equipment, assessment approach, and interpretation. We reviewed four databases (Embase, MEDLINE, the Cochrane Library, and PubMed) for relevant articles published between 1 January 1985 and 10 March 2022. Studies reporting post-operative anorectal manometry in children (<18 years) following anorectal malformation repair were evaluated for eligibility. Sixty-three studies were eligible for inclusion. Of the combined total cohort of 2155 patients, anorectal manometry results were reported for 1755 children following repair of anorectal malformations. Reduced resting pressure was consistently identified in children with anorectal malformations, particularly in those with more complex malformation types and/or fecal incontinence. Significant variability was identified in relation to manometry equipment, protocols, and interpretation. Few studies provided adequate cohort medical characteristics to facilitate interpretation of anorectal manometry findings within the context of the broader continence mechanism. This review highlights a widespread lack of standardization in the anorectal manometry procedure used to assess anorectal function in children following anorectal malformation repair. Consequently, interpretation and comparison of findings, both within and between institutions, is exceedingly challenging, if not impossible. Standardized manometry protocols, accompanied by a consistent approach to analysis, including definitions of normality and abnormality, are essential to enhance the comparability and clinical relevance of results.

Significance of searching for ganglia in the terminal rectum/fistula of complex anorectal malformations: Related to defecation function

Background

The need to search for ganglia in the terminal rectum/fistula of complex anorectal malformations (ARMs) remains controversial. This study aims to evaluate the relationship between ganglia absence in the terminal rectum/fistula and defecation function after anoplasty.

Methods

A retrospective review of patients who received anoplasty for treating male imperforate anus with rectobulbar (RB)/rectoprostatic (RP) fistulas at a tertiary pediatric hospital was conducted with registered demographic data, imaging study results, and information on the terminal rectum/fistula specimen (excision extension and pathological findings). According to the pathological findings, patients were divided into Groups 1 (ganglia absence) and 2 (ganglia presence). Furthermore, the postoperative defecation function was evaluated using various rating scale questionnaires. Statistical analysis was performed using SPSS 22.0.

Results

Of the 62 patients, 18 (29.0%) showed ganglia absence in the terminal rectum/fistula. By analyzing the imaging data, spinal anomalies and spinal cord anomalies were found in 30.6% (19/62) and 56.5% (35/62) of patients, respectively. Baseline information was comparable between Groups 1 and 2 (P > 0.05). For defecation function, there were no significant differences in Kelly scores between the two groups (4.0 ± 0.8 vs. 4.4 ± 1.1, P = 0.177), while Krickenbeck (3.7 ± 1.8 vs. 5.2 ± 1.4) and Rintala (13.7 ± 3.6 vs. 16.0 ± 2.7) scores in Group 1 were significantly lower than those in Group 2 (both P < 0.05). The overall incidence of constipation was 50% (31/62), being higher for Group 1 than Group 2 (77.5% vs. 38.6%, P = 0.002). The area under the curve of ganglia absence for predicting constipation was 0.696, with 77.8% sensitivity and 61.4% specificity.

Conclusion

Ganglia absence in the terminal rectum/fistula of male imperforate anus with RB/RP fistulas is associated with constipation after anoplasty, but it has limited predictive value for postoperative constipation. It is necessary to search for ganglia in the terminal rectum/fistula, both intraoperatively and postoperatively.

One-stage versus staged laparoscopic-assisted anorectoplasty for high-and intermediate anorectal malformations: Medium-term outcomes from a propensity score matching analysis

BACKGROUND

The timing of anorectoplasty for anorectal malformations (ARMs) is controversial and essential for long-term bowel function. The advantages of laparoscopy make primary anoplasty possible for neonates. This study aims to report the medium-term results of the one-stage laparoscopic-assisted anorectoplasty (LAARP) and compare them with the staged LAARP.

METHODS

This study included 242 boys who underwent LAARP between June 2013 and December 2018 in our center. Forty-five neonatal patients successfully underwent the one-stage LAARP, and the remaining 197 patients who had already undergone colostomy received staged procedures. The complications and bowel function were compared between the two groups after 1:1 propensity score matching (PSM).

RESULTS

Before matching, age at assessment and classification were significantly different between the two groups (P < 0.05). After PSM, 42 patients were included in each of the two groups, and the patients were well balanced. The overall occurrence of postoperative complications in the one-stage group was significantly lower than in the staged group (P < 0.05). The median follow-up periods were 55.0 and 54.5 months, respectively. The mean value of BFS was similar in the two groups. After medical management, a second evaluation was conducted to distinguish overflow pseudo-incontinence from patients with no bowel control potential. The functional outcome in the two groups is comparable (P = 0.307).

CONCLUSIONS

One-stage LAARP is safe and feasible for neonates with high-and intermediate-type ARMs. Compared with staged LAARP, one-stage LAARP has fewer complications and comparable functional outcomes. The authors recommend these procedures to be performed in dedicated centers with sufficient expertise.

LEVEL OF EVIDENCE

Level III.

Bowel function and associated risk factors at preschool and early childhood age in children with anorectal malformation type rectovestibular fistula: An ARM-Net consortium study

BACKGROUND

Outcome of patients operated for anorectal malformation (ARM) type rectovestibular fistula (RVF) is generally considered to be good. However, large multi-center studies are scarce, mostly describing pooled outcome of different ARM-types, in adult patients. Therefore, counseling parents concerning the bowel function at early age is challenging. Aim of this study was to evaluate bowel function of RVF-patients at preschool/early childhood age and determine risk factors for poor functional outcome.

METHODS

A multi-center cohort study was performed. Patient characteristics, associated anomalies, sacral ratio, surgical procedures, post-reconstructive complications, one-year constipation, and Bowel Function Score (BFS) at 4-7 years of follow-up were registered. Groups with below normal (BFS < 17; subgroups 'poor' ≤ 11, and 'fair' 11 < BFS < 17) and good outcome (BFS ≥ 17) were formed. Univariable analyses were performed to detect risk factors for outcome.

RESULTS

The study included 111 RVF-patients. Median BFS was 16 (range 6-20). The 'below normal' group consisted of 61 patients (55.0%). Overall, we reported soiling, fecal accidents, and constipation in 64.9%, 35.1% and 70.3%, respectively. Bowel management was performed in 23.4% of patients. Risk factors for poor outcome were tethered cord and low sacral ratio, while sacral anomalies, low sacral ratio, prior enterostomy, post-reconstructive complications, and one-year constipation were for being on bowel management.

CONCLUSIONS

Although median BFS at 4-7 year follow-up is nearly normal, the majority of patients suffers from some degree of soiling and constipation, and almost 25% needs bowel management. Several factors were associated with poor bowel function outcome and bowel management.

LEVEL OF EVIDENCE

Level III.

Assessment of sacral ratio in patients with anorectal malformations: Can magnetic resonance imaging replace conventional radiograph?

INTRODUCTION

In patients with anorectal malformations (ARM), the sacral ratio (SR) serves as an established predictive marker for functional prognosis and is derived from conventional radiographs. More recently, magnetic resonance imaging (MRI) has emerged as a diagnostic alternative for preoperative/baseline assessment of patients with ARM. With this study we aimed to evaluate if the SR could be reliable be measured from MRI images and if it correlated to SR measurements obtained from radiographs.

METHODS

Two raters analyzed MRI data and conventional radiographs from thirty-one subjects (n = 17 with ARM; n = 14 controls). We calculated intra-class correlation coefficients (ICCs) to test inter-rater reliability and applied paired t-tests to examine if SR parameters from MRI were comparable with those from pelvic radiograph. We further computed Pearson's correlation coefficients to test the linear relationship between SR calculated from MRI and conventional radiographs.

RESULTS

The ARM and control groups did not statistically differ in their age and weight on the day of the MRI scan. Reliability analysis revealed an excellent inter-rater agreement for SR from radiograph parameters with an intraclass correlation coefficient (ICC) of 0.94, respectively of 0.86 for MRI (frontal plane), and of 0.84 for MRI (sagittal plane). The correlation coefficient between SR calculated from the sagittal MRI and SR calculated from radiograph images was significant and high (r = 0.80, P < 0.001). The SRs from MRI images did not significantly differ from SRs from radiographs, but were also not statistically equivalent.

CONCLUSION

Our results demonstrate that the SR can be derived from MRI images with good inter-rater reliability. The SR value is marginal higher when calculated on MRI, presumably due to inclusion of cartilaginous yet unossified structures.

Cardiorespiratory performance and locomotor function of patients with anorectal malformations

The aim of this study was to assess whether adolescents following anorectal malformation repair have a decreased cardiorespiratory performance capacity and impaired motor skills. All eligible children treated for ARMs between 2000 and 2014 were invited to participate in a prospective study consisting of a clinical examination, evaluation of Bowel function and Quality of Life, spirometry, spiroergometry and assessment of the motor activity. The results were compared to a healthy age- and sex-matched control group. There was no statistically significant difference in height, weight, BMI, muscle mass or body fat percentage between the study and the control group. Nine out of 18 patients (50%) had an excellent functional outcome with a normal Bowel Function Score. Spirometry revealed no significant differences between ARM patients and controls, four patients showed a ventilation disorder. Spiroergometry revealed a significantly lower relative performance capacity and the overall rating of the motor activity test showed significantly decreased grades in ARM patients. ARM patients were affected by an impaired cardiopulmonary function and decreased motor abilities. Long-term examinations consisting of routine locomotor function evaluation and spiroergometry are advisable to detect impaired cardiopulmonary function and to prevent a progression of associated complications and related impaired quality of life.

Comparison of longitudinal and radial characteristics of intra-anal pressures using 3D high-definition anorectal manometry between children with anoretal malformations and functional constipation

BACKGROUND

Pathophysiology of fecal incontinence (FI) in children with anorectal malformations (AM) is not well understood. Standard or high-resolution anorectal manometry (ARM) does not identify radial asymmetry or localize abnormal sphincter function. 3D high-definition anorectal manometry (HDARM) provides detailed topographic and 3D pressure gradient representation of anal canal.

AIMS

To compare intra-anal pressure profiles between children with AM and controls using HDARM and to determine the association between manometric properties and reported predictors of fecal continence (AM type, spinal anomaly, and sacral integrity).

METHODS

HDARM tracings of 30 children with AM and FI referred for ARM were compared with 30 age and sex-matched children with constipation. 2D pressure profiles were used to measure length of high-pressure zone (HPZ). Longitudinal and radial measurements of sphincter pressure at rest and squeeze were taken along each segment in 3D topographic views and compared between groups.

KEY RESULTS

3D measurements demonstrated longitudinal and radial differences between groups along all quadrants of HPZ. At rest, intra-anal pressures were lower along the four segments longitudinally across the anal canal and radially along the quadrants in AM group (P < .01). At squeeze, all quadrant pressures were lower in segments 1-4 in AM group (P < .01). Sensation was abnormal in AM group (P < .01). Intra-anal pressures longitudinally and radially were not associated with predictors of fecal continence.

CONCLUSIONS AND INFERENCES

Children with AM had abnormal sensation and lower pressures longitudinally and radially along all quadrants of anal canal. Manometric properties at rest were not associated with reported predictors of fecal continence.

Spatiotemporal expression of neurogenic locus notch homolog protein 1 in developing caudal spinal cord of fetuses with anorectal malformations from ETU-fed rats

Complications, such as fecal soiling, incontinence, and constipation, are major health issues for patients with anorectal malformations (ARMs) after surgery. Dysplasia of the caudal spinal cord is an increasingly pivotal area in the field of postoperative complications for patients with ARMs. However, the existing research has not fully defined the mechanism underlying ARMs development. The neurogenic locus notch homolog (Notch) signaling pathway comprises several highly conserved proteins that are involved in spinal cord developmental processes. In the present study, the emerging role of Notch1 in fetal lumbosacral spinal cords was investigated in a rat model of ARMs using ethylene thiourea. Immunohistochemical staining, western blot and quantitative reverse transcription real-time polymerase chain reaction were utilized to analyze spatiotemporal expression of Notch1 on embryonic days (E) 16, E17, E19, and E21. The expression levels of the neuronal marker neurofilament and recombination signal-binding protein-J protein were evaluated for temporal correlations to Notch1 expression. The results implied that Notch1 expression was reduced in lumbosacral spinal cord neurons of ARMs embryos compared to control embryos. These results showed that, in ARMs embryos decreased Notch1 expression is related to the dysplasia of the caudal spinal cord during embryogenesis, indicating that Notch signaling may participate pathogenic embryonic lumbosacral spinal development and may be associated with postoperative complications of ARMs.

Long term bowel function after repair of anorectal malformations in Uganda

BACKGROUND

Anorectal malformations (ARMs) are common congenital anomalies cared for at Mulago Pediatric Surgery Unit (PSU), similar to other sites in the region. All patients undergo staged repairs and complete treatment at older ages compared to high-income countries (HICs). This is the first study to examine long-term bowel function in our patients and compare with HICs.

METHODS

A retrospective cohort study was conducted of all children 3-12 years old with ARMs who had repair between January 2012 and June 2017 and who completed surgical repair at least 6 months prior to the study. Bowel function was measured using the fecal continence scoring system derived from Rintala and Lindahl (1995). As in prior studies, patients were classified by score into four categories: Poor (6-9); Fair (9-11); Good (12-17); and Normal (18-20).

RESULTS

Median follow up was 2 years post stoma closure. Long-term bowel function was Normal/Good in 65% (C.I 27, 45), and Fair/Poor 35% (C.I 55, 73), with soiling in 49% (C.I 40, 59), constipation in 23% (C.I 16, 32); and incontinence in 39% (C.I 30, 39). There was no statistically significant association between bowel function and multiple demographic, social, and clinical factors. Median age at completion of treatment (stoma reversal) was 2.3 years old, and median duration of colostomy (interval between stoma placement and takedown) was 1.8 years.

CONCLUSION

Despite definitive repair at older age and almost two years of living with a stoma, our patients achieve fair long-term bowel function. Nonetheless, improved follow up and timely management of complications may improve outcomes soiling, incontinence and constipation.

LEVEL OF EVIDENCE

Level II.

Urinary Tract Anomalies in Patients With Anorectal Malformations: The Role of Screening and Clinical Follow-Up

OBJECTIVE

To evaluate the efficacy of the screening protocol and the clinical follow-up to detect urological anomalies (UA) in patients with ARM (ARM-P) in our institution. Secondary aim was to define the prevalence of UA and their relationship with severity of ARM.

METHODS

ARM-P were selected from a prospectively maintained database from 2000 to 2016. Exclusion criteria were: incomplete or with less than 3 years of follow-up and absence of surgical correction of the anorectal anomalies. Data from urological screening and follow-up were collected. Patients were divided into complex malformations (Group 1) and less complex malformations (Group 2).

RESULTS

One hundred seventeen of 149 were included in the study period (62 group 1, 55 group 2). UA were detected in 36/117 at birth (30.7%) with a difference between groups (P = .0005). VUR was detected in 16 (6 with hydronephrosis, 10 with normal ultrasound at birth). A bladder ultrasound after potty training showed 18 lower urinary tract dysfunction (LUTD; 15 with UA detected at birth, 3 with normal ultrasound). 8 LUTD were found during clinical follow-up, confirmed by ultrasound. Spinal MRI detected spinal cord anomalies (SCA) in 52/117 (44.4%). Considering the subgroups with neurogenic bladder and SCA there was a difference between groups (13/33 vs 1/19).

CONCLUSION

This study suggests that ARM-P are at increased risk of UA, most of which were detected on neonatal ultrasound. While screening protocol can show 88% of UA, follow-up can detect 12.9 % of total abnormalities without difference between groups. This data has to be considered when planning follow-up for these patients.

Scientific solution to a complex problem: physiology and multidisciplinary team improve understanding and outcome in chronic constipation and faecal incontinence

PURPOSE

There is a lack of diagnostic credibility to direct focused management for children with chronic constipation (CC) and faecal incontinence (FI). The aim is to assess the impact of an innovative Children's Anorectal Physiology Service (CAPS) focusing on improving outcomes in children with CC/FI.

METHODS

Prospective data: demographics, bowel and quality of life (QoL)/risk of distress questionnaires. Diagnostics: awake high-resolution anorectal manometry (AHRAM), endoanal ultrasound and transit marker studies (TMS).

RESULTS

Total patients: 112; 66 males (59%); median 9 years (17 months to 16 years). Patient groups included: 89 (79%) had functional CC/FI; 9 (8%), Hirschsprung's disease; 12 (11%), anorectal malformations and 2 (2%), trauma. St Marks Incontinence score (SMIS) abnormal in 91 (81%) and Cleveland Constipation Score (CCS) in 101 (90%) patients. Anorectal manometry: 94 (84%) awake and 18 (17%) under anaesthesia. Play specialist input 37 (33%) patients. AHRAM abnormal 65 (58%): sphincter dysfunction 36 (32%) and altered rectal sensation: hyposensitive 22% (20/91); 21% (19/91) hypersensitive. TMS normal in 64 (57%), 17 (15%) slow transit and 27 (24%) rectal evacuatory disorder. Risk of distress in 38% and poor QoL in 55% patients which correlated with abnormal SMIS (p = 0.02). Patient/parent satisfaction improved significantly (p < 0.05).

CONCLUSIONS

Scientific investigations combined with multidisciplinary team improve patient satisfaction and reduces patient self-report illness severity. A complex problem requires a scientific solution.

Anorectal malformation patients' outcomes after definitive surgery using Krickenbeck classification: A cross-sectional study

Background

The survival of anorectal malformation (ARM) patients has been improved in the last 10 years because of the improvement in management of neonatal care and surgical approaches for ARM patients. Thus, the current management of ARM patients are focusing on the functional outcomes after definitive surgery. Here, we defined the type of ARM and assessed the functional outcomes, including voluntary bowel movement (VBM), soiling, and constipation, in our patients following definitive surgery using Krickenbeck classification.

Methods

We conducted a cross-sectional study to retrospectively review medical records of ARM patients who underwent a definitive surgery at Dr. Sardjito Hospital, Indonesia, from 2011 to 2016.

Results

Forty-three ARM patients were ascertained in this study, of whom 30 males and 13 females. Most patients (83.7%) were normal birth weight. There were ARM without fistula (41.9%), followed by rectourethral fistula (25.5%), perineal fistula (18.6%), vestibular fistula (9.3%), and rectovesical fistula (4.7%). The VBM was achived in 53.5% patients, while the soiling and constipation rates were 11.6% and 9.3%, respectively. Interestingly, patients with normal birth weight showed higher frequency of VBM than those with low birth weight (OR = 9.4; 95% CI = 1.0–86.9; p = 0.04), while male patients also had better VBM than females (OR = 3.9; 95% CI = 1.0–15.6) which almost reached a significant level (p = 0.09). However, VBM was not affected by ARM type (p = 0.26). Furthermore, there were no significant associations between gender, birth weight, and ARM type with soiling and constipation, with p-values of 1.0, 1.0, and 0.87; and 0.57, 1.0, and 0.94, respectively.

Conclusions

Functional outcomes of ARM patients in our hospital are considered relatively good with more than half of children showing VBM and only relatively few patients suffering from soiling and constipation. The frequency of VBM might be associated with birth weight and gender, but not ARM type, while the soiling and constipation did not appear to be correlated with birth weight, gender, nor ARM type. Further multicenter study is necessary to compare our findings with other centers.

Abnormal serum vitamin A levels and retinoic acid receptor α expression patterns in children with anorectal malformation

BACKGROUND

Anorectal malformation (ARM) is known to be associated with maldevelopment of the enteric nervous system (ENS), and vitamin A (VA) and its metabolite retinoic acid (RA) play important roles in ENS development. Thus, our aim was to investigate serum VA levels in ARM newborns and RA receptor (RAR) expression in the rectum of ARM patients and animal models.

METHODS

Serum VA concentrations were detected in newly diagnosed ARM neonates (n = 32) and neonates with non-alimentary tract malformations (n = 30). Intestinal specimens were divided into three groups: rectum from ARM patients (n = 30), colon from a stoma (n = 30) and rectum from controls (n = 4). RAR mRNA expression was evaluated by RT-qPCR. Rectum specimens from ARM patients were divided into two groups by postoperative pathology: the normal and lesion ganglion cell groups. Immunohistochemistry and Western blot were employed to detect RARα protein expression in rectum specimens. In addition, the ARM mouse model was induced by all-trans retinoid acid (ATRA), and the expression levels of RARα and the neuronal marker NeuN in the rectum of mice on embryonic day 16.5-18.5 (E16.5-18.5) were investigated.

RESULTS

The serum concentration of VA in ARM neonates was lower than that in control neonates (P < 0.0001), and RARα mRNA expression was lower in the rectum specimens from ARM patients than in the colon specimens from a stoma and the rectum specimens from controls (P < 0.05); there was no significant difference between the colon from a stoma and the rectum from controls. RARα protein was expressed in the nucleus of ganglion cells and nerve fibers, and RARα protein expression in the lesion ganglion cell group was significantly lower than that in the normal ganglion cell group (P < 0.01). Compared with the control mice, ARM mice at E16.5-18.5 showed decreased fluorescence intensity of RARα and NeuN in the rectum. RARα and NeuN mRNA expression in the rectum on E16.5-18.5 was lower in ARM mice than in control mice (P < 0.05).

CONCLUSION

Serum VA concentration and the RARα expression pattern are abnormal in the rectum in ARM and may contribute to the ENS maldevelopment in ARM.

Can fecal continence be predicted in patients born with anorectal malformations?

PURPOSE

The purpose of this study was to identify factors associated with attaining fecal continence in children with anorectal malformations (ARM).

METHODS

We performed a multi-institutional cohort study of children born with ARM in 2007-2011 who had spinal and sacral imaging. Questions from the Baylor Social Continence Scale were used to assess fecal continence at the age of ≥4 years. Factors present at birth that predicted continence were identified using multivariable logistic regression.

RESULTS

Among 144 ARM patients with a median age of 7 years (IQR 6-8), 58 (40%) were continent. The rate of fecal continence varied by ARM subtype (p = 0.002) with the highest rate of continence in patients with perineal fistula (60%). Spinal anomalies and the lateral sacral ratio were not associated with continence. On multivariable analysis, patients with less severe ARM subtypes (perineal fistula, recto-bulbar fistula, recto-vestibular fistula, no fistula, rectal stenosis) were more likely to be continent (OR = 7.4, p = 0.001).

CONCLUSION

Type of ARM was the only factor that predicted fecal continence in children with ARM. The high degree of incontinence, even in the least severe subtypes, highlights that predicting fecal continence is difficult at birth and supports the need for long-term follow-up and bowel management programs for children with ARM.

TYPE OF STUDY

Prospective Cohort Study.

LEVEL OF EVIDENCE

II.

Clinical characteristics, prognosis, and its risk factors of anorectal malformations: a retrospective study of 332 cases in Anhui Province of China

Objective: To analyze the clinical characteristics and prognosis of anorectal malformations (ARMs) and explore the influencing factors of postoperative anal function in Anhui Province of China.Methods: We performed a retrospective study of ARM patients diagnosed from 2013 to 2016 at Anhui Provincial Children's Hospital. A total of 332 infants with ARM were enrolled in the survey. Demographic characteristic and clinical data were collected. Follow-up study was required to evaluate anal function after the operation and Logistic regression analysis was used for analyzing the influencing factors of prognosis.Results: A total of 253 males and 79 females were studied, with a ratio of 3.2:1. Abdominal distention was the most common presenting symptom, followed by vomiting. Of the cases, 53.0% (176/332) combined with other congenital malformations. The incidence of other malformations in intermediate and high ARM group was significantly higher than that in the low ARM group. Of the cases, 280 underwent anoplasty. 188, 73, 19 cases were treated with one-stage perineal anoplasty, posterior sagittal anorectoplasty, laparoscopically assisted anorectal pull-through, respectively. The result of follow-up study showed that the excellent and good rate of postoperative anal function was up to 83.3%. Type of ARM, combined with other malformations and the times of anoplasty were related to the anal function postoperatively.Conclusions: ARM occurs mainly in male infants. The incidence of associated abnormalities in ARM patients was high. Intermediate- and high-type, combined with other malformations and more times of anoplasty increased the risk of anal dysfunction postoperatively. Multicenter, prospective randomized-controlled studies were needed to clarify the curative effect of different surgical approaches.

Continence after posterior sagittal anorectoplasty for anorectal malformations: comparison of different scores

PURPOSE

To evaluate bowel function in patients with anorectal malformations (ARM) comparing existing scoring systems.

METHODS

Parents of ARM patients treated at our institution were asked to fill in Holschneider, Kricknebeck, and Rintala questionnaires. Scores obtained from the questionnaires were expressed per cent and analyzed depending on the age and type of ARM according to Krickenbeck classification. Patients younger than 3 years of age or with developmental delay were excluded.

RESULTS

Eighty patients (42 males: 52%) were included. Median age was 7.6 years (range 3-22). Twenty eight patients (35%) had perineal fistula, 13 (16%) bulbar, 7 (9%) prostatic, 5 (6%) rectobladder neck, 15 (19%) vestibular, 7 (9%) had a cloaca and 5 (6%) imperforate anus without fistula. Using Holschneider, Krickenbeck, and Rintala, average scores were respectively 72, 71 and 73 (p = 0.4 with ANOVA). Using the three questionnaires patients with perineal fistula scored 82, 76 and 84 respectively (p = 0.003), with bulbar 70, 71, 73 (p = 0.8), with prostatic 52,69,59 (p = 0.06), with bladder neck 56, 80, 57 (p = 0.004), with vestibular 75,67,75 (p = 0.02), with cloaca 64, 67, 65 (p = 0.9), and with imperforate anus without fistula 61,49, 53 (p = 0.12). Patients from 3 to 6 years of age scored 74,72 and 76 (p = 0.37), from 7 to 12: 70,71 and 71 (p = 0.87), and older than twelve: 74,66 e 73 (p = 0.08).

CONCLUSION

The scores obtained using Holschneider, Rintala, and Krickenbeck questionnaires are significantly lower with increasing severity of the ARM. For each type of ARM there are some differences in the results obtained using the three questionnaires. In general, Krickenbeck and Peña questionnaires tend to give lower scores in patients with ARMs that have good prognosis, and higher scores for ARMs with poor prognosis. Age is not significantly related to the score obtained.

LEVEL OF EVIDENCE

III TYPE OF STUDY: Diagnostic study.

No-fistula vs. fistula type anorectal malformation: Outcome comparative study

INTRODUCTION

Anorectal malformation (ARM) is a congenital defect that exists in varying presentations and no-fistula type (NFT) ARM is a rare high-type category. We aim to report our experience with management of this anomaly and its outcome, compared to the more common fistula-type (FT) ARM.

METHODS

A retrospective review of medical records of patients diagnosed with high ARM and 3years and older, for the period between September 2000 and January 2015 was conducted. Demographic, anatomic, and outcome data were obtained for each group and compared. Quality of life data were collected using the Krickenbeck classification and assessed as documented at clinic visits as well as phone interviews.

RESULTS

There were 100 patients managed for ARM during that period and were 3years or older. Sixteen of them were NFT (16%). For comparison purposes each NFT patient was matched with 3 FT patients. We have analyzed data on 44 patients with FT (44 males), and 16 with NFT (12 males and 4 females). The occurrence of Down syndrome in NFT patients was 56.2% compared to 0% in the FT patients (p=<0.0001). Quality of Life data showed no significant differences between the two groups with p-values of 0.39, 1.0, and 1.0 for Voluntary Bowel Movement, Soiling, and Constipation respectively.

CONCLUSION

NFT ARM represents a significant number at our population (16%). There is a strong association between NFT ARM and Down syndrome. NFT ARM has similar outcomes compared to the FT ARM.

TYPE OF STUDY

Clinical research paper.

LEVEL OF EVIDENCE

Level III.

Bone morphogenetic protein 4 expression in the developing lumbosacral spinal cord of rat embryos with anorectal malformations

Although there are improvements in treatment of anorectal malformations (ARMs), patients can still develop fecal incontinence, constipation, and soiling with loss in quality of life. Recent evidence suggests that malformations in the lumbosacral spinal cord are one of the factors that affect postoperative anorectal function. However, the underlying mechanism that produces these malformations has yet to be elucidated. The bone morphogenetic proteins (BMPs) comprise a large group of highly conserved molecules that are involved in multiple processes and play important roles in the formation, development, and differentiation of the spinal cord. This study was designed to investigate the levels of BMP4 expression in the lumbosacral spinal cord in ARMs rat embryos induced by ethylenethiourea (ETU). Specifically, we assessed the association of BMP4 levels with the maldevelopment of the lumbosacral spinal cord and whether BMP4 acted through the canonical intracellular pathway in embryonic rats with ARMs. BMP4 expression was confirmed with immunohistochemical staining, RT-qPCR and western blot analyses of embryonic day (E) 16, E17, E19 and E21 embryos, moreover Smad1/5 and pSmad1/5 expression were confirmed with western blot analyses at peak time point of BMP4 expression. Our results reveal that BMP4 expression in the lumbosacral spinal cord of ARMs rat embryos is decreased at both the mRNA and protein levels and could decrease the phosphorylation of smad1/5, when compared with their expression levels in normal tissue. These results also suggest that reductions in BMP4 expression were possibly responsible for dysfunction of the lumbosacral spinal cord during late developmental stages in ARMs fetal rats. Taken together, we conclude a role for BMP4 in the pathogenesis of lumbosacral spinal cord maldevelopment in developing ARMs rats.

Challenges in Transition of Care for Patients With Anorectal Malformations: A Systematic Review and Recommendations for Comprehensive Care

BACKGROUND

Anorectal malformations are one of the most common congenital intestinal anomalies affecting newborns. Despite advances in neonatal care and surgical techniques, many patients with a history of anorectal malformations are affected by long-term challenges involving bowel and bladder dysfunction, sexual dysfunction, and psychosocial issues. These outcomes or challenges are additionally exacerbated by the lack of a structured transition of care from the pediatric to the adult setting.

OBJECTIVE

The purpose of this review is to describe the long-term outcomes affecting patients with a history of anorectal malformations, review the current literature on transition of care, and make recommendations for developing a standardized program for transitioning care for a select group of colorectal surgical patients.

DATA SOURCES

An extensive PubMed review of articles in English was performed to evaluate current best practices for chronic illnesses of childhood with residual symptoms or need for medical care into adulthood.

STUDY SELECTION

Meta-Analysis of Observational Studies in Epidemiology group guidelines were followed.

MAIN OUTCOME MEASURES

The primary outcome for this review was the existence of transitional services for patients with a history of anorectal malformations and evaluations of long-term outcomes affecting patients with a history of anorectal malformations.

RESULTS

Systematic review revealed improved results in transition programs as determined by patient follow-up, medication adherence, and patient and family satisfaction through the use of multidisciplinary teams. Standardized tools for assessing all aspects of patient outcomes and quality of life are essential for describing the burden of disease affecting a transitioning population.

LIMITATIONS

This is a retrospective review of the current status of a complex and rapidly evolving field of delivery of care. More work is needed to apply uniform approaches and assess the impact, patient outcomes, and quality of life.

CONCLUSIONS

Patients who undergo childhood procedures for anorectal malformations often experience chronic symptoms related to the bowel, bladder, and reproductive organs, as well as psychosocial disturbances. This population will benefit from appropriate engagement in transitional care plans. See Video Abstract at http://links.lww.com/DCR/A543.

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.

A standardized approach for the assessment and treatment of internationally adopted children with a previously repaired anorectal malformation (ARM)

INTRODUCTION

A significant number of internationally adopted children have congenital birth defects. As a specialist center for colorectal diagnoses, we evaluate such children with an anorectal malformation (ARM) and have found that a significant number need a reoperation. Knowledge of the common complications following ARM surgery has led us to develop treatment algorithms for patients with unknown past medical and surgical history, a situation typically encountered in the adopted population.

METHODS

The results of investigations, indications, and rate of reoperation were assessed for adopted children with an ARM evaluated between 2014 and 2016.

RESULTS

56 patients (28 males) were identified. 76.8% required reoperative surgery. Mislocation of the anus outside the sphincter complex was seen in 50% of males and 39.3% of females. Anal stricture, rectal prolapse, retained vaginal septum, and a strictured vaginal introitus were also common.

CONCLUSION

The reoperative surgery rate in the internationally adopted child with an ARM is high. Complete, systematic evaluation of these children is required to identify complications following initial repair. Development of mechanisms to improve the primary surgical care these children receive is needed.

Imperforate Anus with Fistula Exiting at the Penile Skin

We present the case of a male neonate with imperforate anus and a fistula exiting on the penile skin. Anorectal malformations in boys often present themselves with an entero-perineal or entero-urinary tract fistula, the type of which is a key feature for the classification and the treatment plan. A fistula exiting in front of the scrotum, such as described in our case, is very rare and is not incorporated in the current classification and treatment algorithms. Scarce reports on misjudgment concerning the position of the blind rectal pouch in similar cases, led us to perform a colostomy instead of a one-stage correction. A posterior sagittal anorectoplasty was performed eight months later and the rectal pouch was found inside the levator sling, justifying the cautious approach. The colostomy was closed three months later and after six months the distal part of the fistula was excised. We believe that in cases with a rare fistula presentation, the position of the rectal pouch is not predictable and the surgeon should proceed with caution.

Congenital anomaly rectified at birth: one-stage single-incision laparoscopic-assisted anorectoplasty for newborns with anorectal malformations and recto-urethral fistula

OBJECTIVE

Currently, staged procedures involving stoma formation and closure are the widely accepted treatment for newborns suffering from anorectal malformations (ARM) with recto-urethral fistula. This study aims to evaluate the safety and efficacy of one-stage single-incision laparoscopic-assisted anorectoplasty (SILAARP) as an alternative to the conventional approach.

METHODS

Newborns with ARMs and recto-urethral fistula who underwent one-stage SILAARP between June 2013 and December 2014 were reviewed. The procedure involved decompression of the meconium via a small temporary incision of the proximal sigmoid colon followed by a laparoscopic-assisted pull-through.

RESULTS

Sixteen ARM newborns [recto-prostatic fistula (6), recto-bulbar fistula (10)] successfully underwent a one-stage SILAARP. The mean age of the neonates at operation was 42.1 h. The average operative time was 2.4 h. The actual pull-through took 1.7 h, which did not differ significantly from 1.9 h in the pull-through procedure of our three-stage SILAARP control group. The median follow-up period was 16 months (8-26 months). No complications were encountered. Postoperative pelvic magnetic resonance imaging verified the centrally placed rectum within the muscle complex. Most patients started having bowel movements on postoperative day 1. Two constipated patients periodically required an enema for 1-3 months.

CONCLUSIONS

One-stage SILAARP is safe and effective. It provides complete rectification of ARM with recto-urethral fistula immediately after birth with good cosmesis.