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

Rectal Prolapse Following Repair of Anorectal Malformation: Incidence, Risk Factors, and Management

BACKGROUND

The incidence and optimal management of rectal prolapse following repair of an anorectal malformation (ARM) has not been well-defined.

METHODS

A retrospective cohort study was performed utilizing data from the Pediatric Colorectal and Pelvic Learning Consortium registry. All children with a history of ARM repair were included. Our primary outcome was rectal prolapse. Secondary outcomes included operative management of prolapse and anoplasty stricture following operative management of prolapse. Univariate analyses were performed to identify patient factors associated with our primary and secondary outcomes. A multivariable logistic regression was developed to assess the association between laparoscopic ARM repair and rectal prolapse.

RESULTS

A total of 1140 patients met inclusion criteria; 163 (14.3%) developed rectal prolapse. On univariate analysis, prolapse was significantly associated with male sex, sacral abnormalities, ARM type, ARM complexity, and laparoscopic ARM repairs (p < 0.001). ARM types with the highest rates of prolapse included rectourethral-prostatic fistula (29.2%), rectovesical/bladder neck fistula (28.8%), and cloaca (25.0%). Of those who developed prolapse, 110 (67.5%) underwent operative management. Anoplasty strictures developed in 27 (24.5%) patients after prolapse repair. After controlling for ARM type and hospital, laparoscopic ARM repair was not significantly associated with prolapse (adjusted odds ratio (95% CI): 1.50 (0.84, 2.66), p = 0.17).

CONCLUSION

Rectal prolapse develops in a significant subset of patients following ARM repair. Risk factors for prolapse include male sex, complex ARM type, and sacral abnormalities. Further research investigating the indications for operative management of prolapse and operative techniques for prolapse repair are needed to define optimal treatment.

TYPE OF STUDY

Retrospective cohort study.

LEVEL OF EVIDENCE

II.

Perioperative outcomes of laparoscopically assisted anorectoplasty versus conventional procedures for anorectal malformation: a retrospective nationwide database study

PURPOSE

This study aimed to compare the perioperative outcomes of laparoscopically assisted anorectoplasty (LAARP) and conventional procedures (CPs) for anorectal malformation (ARM) using a national inpatient database in Japan.

METHODS

Using the Diagnosis Procedure Combination database, we identified patients who underwent anorectoplasty for high- or intermediate-type ARMs from 2010 to 2019. Primary outcomes were postoperative rectal prolapse, anal stenosis, and general complications. Secondary outcomes were the duration of anesthesia and length of hospital stay. We performed 1:2 propensity score-matched analyses to compare the outcomes between the LAARP and CP groups.

RESULTS

We identified 1005 eligible patients, comprising 286 and 719 patients who underwent LAARP and CP, respectively. The propensity score-matched groups included 281 patients with LAARP and 562 with CP. The LAARP group showed a higher proportion of rectal prolapse (21.4% vs. 8.5%; odds ratio, 2.91; 95% confidence interval [CI], 1.89-4.48; p < 0.001) and longer duration of anesthesia (462 min vs. 365 min; difference, 90 min; 95% CI 43-137; p < 0.001) than the CP group. No significant differences were found in other outcomes.

CONCLUSION

LAARP had worse outcomes than CP in terms of rectal prolapse. Thus, we propose that LAARP may require technical refinement to improve patient outcomes.

Pattern of anatomic disorder and surgical management of anorectal prolapse in anorectal malformation

AIM

Due to the paucity of data and controversy regarding the etiology and surgical approach for managing anorectal prolapse (ARP) after anorectoplasty, we sought to investigate the underlying anatomic disorder and the surgical outcome in managing this challenging complication.

METHODS

We performed a retrospective study on 83 patients with ARP related to anorectal malformations (ARM). Logistic regression analyses were performed to detect the risk factors for the ARP severity. Surgical procedures were stratified according to identified anatomical abnormalities and surgical outcomes were analyzed.

RESULTS

50 patients (62.7%) had high-type ARM. The original anorectoplasty had a higher rate of ARP in laparoscopic-assisted anorectoplasty (n = 49, 59.0%) versus posterior sagittal anorectoplasty (n = 11, 13.3%). ARP was associated with rectal fat hyperplasia (67.5%), dilated muscular tunnel (79.5%), longitudinal muscle (LM) discontinuity (16.9%), rectal dilation (22.9%), mislocated anus (7.2%), and excessive mobile mesorectum (3.6%). Based on the ARP severity, the patients were divided into a severe group (Group 1, n = 38) and a moderate group (Group 2, n = 45). Binary logistic regression analysis showed that hyperplasia rectal fat (OR 4.55, 95% CI 1.16-17.84), rectal dilation (OR 4.21, 95% CI 1.05-16.94), and high-type ARM (OR 2.90, 95% CI 1.14-7.39) were independent risk factors for the development of severe ARP. Complications after stratified surgical repair included wound infection in six patients (7.2%), anal stenosis in one patient (1.2%), and ARP recurrence in two patients (2.4%). Twenty-six patients without colostomy before prolapse repair were followed up for 2 to 12 years. All the patients maintained voluntary bowel movements. Following ARP repair, there was an overall higher rate of no soiling or grade 1 soiling (88.5 vs. 65.4%), but 3 of 12 patients with grade 2 constipation were upgraded to grade 3.

CONCLUSION

Our study shows that ARM-related anorectal prolapse is associated with excessive rectum, hyperplasia of rectal fat, mobile mesorectum, loose muscular tunnel, LM discontinuity, and anal mislocation. Surgical repair with techniques stratified according to the patients' underlying risk factors is effective to prevent recurrence and improve the soiling continence.

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

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

Assessing the previously repaired patient with an anorectal malformation who is not doing well

In this review, the care of children with a previously repaired anorectal malformation is explored. We know that the surgical care of children with anorectal malformations is complex; however, despite an increased understanding of the congenital anomaly and significant technical advances in the operative repair, many of these children continue to have poor functional outcomes. In this article we focus on the common surgical complications, discuss typical presentations, consider appropriate investigations, and review the risks and benefits of revisional surgery in those patients that are 'not doing well' following their primary reconstruction.

Rectal Prolapse After Laparoscopically Assisted Anorectoplasty for Anorectal Malformations

Aim: To clarify the characteristics of patients with rectal prolapse after laparoscopically assisted anorectoplasty (LAARP), estimate the causes, and evaluate its impact on postoperative bowel function. Methods: The medical records of patients who underwent LAARP for high- or intermediate-type anorectal malformation between 2000 and 2019 were retrospectively reviewed. Clinical data were compared between patients with (Group P) and without prolapse (normal, Group N). Fecal continence was evaluated using the clinical assessment score for fecal continence developed by the Japanese Study Group of Anorectal Anomalies. For patients who underwent pelvic magnetic resonance imaging (MRI) before LAARP, atrophy, or asymmetry of the anal sphincter and levator ani was evaluated by a radiologist. Results: Of the 49 patients, 29 (59%) had rectal prolapse after LAARP (Group P) and 20 did not (Group N). We found no significant difference in gender, type of malformations, incidence of associated spinal or lumbosacral anomalies, procedure time, and postoperative bowel function at ages 4, 8, 12, and 16 years. However, LAARP was performed significantly earlier in Group N (median [range], 180 [123-498] days) than in Group P (210 [141-570] days). In Group P, 18 patients (62%) developed prolapse before colostomy takedown. Eight of 26 patients who underwent surgical prolapse repair required redo procedures. Twenty-five patients who underwent preoperative pelvic MRI showed no significant relationship between the muscular abnormalities and the incidence of postoperative rectal prolapse. Conclusions: Although recurrence is common, performing LAARP at a younger age might prevent postoperative prolapse development.

Laparoscopic-assisted anorectoplasty for intermediate type rectovestibular fistula: a preliminary report

PURPOSE

Laparoscopic-assisted anorectoplasty (LAARP) is considered to benefit the male patients with anorectal malformation (ARM). This study evaluates LAARP management for intermediate type rectovestibular fistula (IRVF) in the female patient with ARM.

METHODS

Twelve patients with IRVF (aged 3-5 months) underwent LAARP from 2017 to 2019 in our institute. LAARP was performed for mobilization of the rectum, visualization and enlargement of the center of the sphincter muscle complex (SMC) from pelvic and perineal aspects, intra-fistula mucosectomy and rectal pull-through in the SMC with the fourchette and the perineal body unattached.

RESULTS

LARRP was performed in all patients without conversion to open procedure. No patient suffered from wound infection, vaginal injury, recurrent fistula and anal stenosis. The parents were satisfied with the appearance of the wound. Rectal prolapse developed in one patient and needed surgical correction. The patients were followed up for a mean of 19.7 months (ranged from 12 to 35 months).

CONCLUSION

Our preliminary experience shows that LAARP offers an alternative method of correction for the IRVF with good visualization of the SMC and may diminish the risks of wound dehiscence and vaginal injury.

Minimal dissection of posterior wall of rectum reduces rectal prolapse in laparoscopic assisted anorectal pull-through

PURPOSE

To determine if minimal dissection of the posterior wall of rectum can reduce rectal prolapse after laparoscopic assisted anorectal pull-through (LAARP) in male anorectal malformation (ARM) with rectourethral fistula.

METHODS

Eighty-six male patients with ARM who underwent LAARP in our center between 2007 and 2018 were retrospectively analyzed. There were 45 cases of prostatic urethral fistula, 24 bulbar urethral fistulas, and 15 bladder neck fistulas. Two patients had no fistula. To prevent rectal prolapses, we markedly shortened the length of posterior rectal dissection from mid-2016. Dissection of posterior wall of rectum was performed minimally around the level of the fistula and the dissected portion of the posterior rectum was significantly shorter than the previous cases. For comparative analysis, patients were divided into two groups (before and after application of minimal dissection of posterior wall of rectum): Group A, from 2007 to mid-2016 and Group B, from mid-2016 to 2018.

RESULTS

There were 60 patients in Group A and 26 patients in Group B. Demographic characteristics were not significantly different between the two groups. The median follow-up duration was 52.4 months for Group A and 26.9 months for Group B. Group B had lower incidence of rectal prolapse (11.5%) than Group A (68.3%) (p < 0.001). Upon our subgroup analysis based on types of fistula, patients with recto-prostatic urethral fistula and recto-bulbar urethral fistula showed significant reduction in the incidence of rectal prolapse (both p < 0.001). However, patients with recto-bladder neck fistula showed no statistical significance (p = 0.264).

CONCLUSION

Minimal dissection of the posterior wall of rectum can reduce rectal prolapse in LAARP.

LEVEL OF EVIDENCE

III. Retrospective Comparative Treatment Study.

Laparoscopic surgical technique to enhance the management of anorectal malformations: 330 cases' experience in a single center

PURPOSE

Laparoscopic-assisted anorectoplasty (LAARP) is considered to benefit the patients with vesico-prostatic fistula. The aim of this study is to present the details of our LAARP technique for improving the short- and long-term outcomes in the patients with high and intermediate types of anorectal malformations (ARMs).

METHODS

330 patients with high-type (174 cases) and intermediate-type (156 cases) anorectal malformation (aged 8 days to 15 years) underwent LAARP from 2001 to 2019. LAARP was performed for full mobilization and resection of the dilated rectum, intra-rectal closure of the fistula, visualization, and enlargement of the center of the longitudinal muscle tube (LMT) from pelvic and perineal aspects.

RESULTS

LAARP was performed in all patients and no patient was converted to open procedure. The urethral diverticulum was found in three patients (1.02%, 3/294) according to postoperative protocol voiding cystourethrogram but was not associated with any symptoms such as urinary tract infection and dysuria. Rectal prolapse requiring surgical intervention developed in 25 (7.6%) of 330 patients. Anal stricture occurred in three patients and re-do anoplasty was performed 5 months after LAARP. Anal retraction occurred in two patients and re-pull-through was conducted at 5 and 6 days, respectively, after LAARP. 228 patients who were older than 3 years were followed up. The median follow-up period was 5.8 years (range 3-15 years). 217 patients (95.2%) had voluntary bowel movements; 202 patients (88.6%) were free from soiling or with grade 1 soiling; 30 patients (13.6%) and 25 patients (11.3%) suffered from grade 1 and grade 2 constipation, respectively, while no patient had grade 3 constipation.

CONCLUSION

Our experience demonstrates that the LAARP has advantages on rectal mobilization and resection, intra-rectal fistula closure and accurate tunnel formation in the LMT with minimal trauma. The improvement of the short-term and long-term outcomes after LAARP has been shown not only for high-type ARM but also for intermediate-type ARM.

Assessing the long term manometric outcomes in patients with previous laparoscopic anorectoplasty (LARP) and posterior sagittal anorectoplasty (PSARP)

BACKGROUND/PURPOSE

The objective of this study is to compare the long term manometric outcomes in patients with previous laparoscopic anorectoplasty (LARP) and posterior sagittal anorectoplasty (PSARP).

METHODS

This is a single-centered retrospective study and the participants were born with various types of anorectal malformation. Manometric assessment was carried out with high-resolution anorectomanometry performed as a day procedure. In addition, a seven-itemed bowel function score (BFS) was utilized to assess the functional outcomes.

RESULTS

A total of 30 patients were included in this study (PSARP=14, LARP=16) and the median follow up periods were 15.5years and 9years in the PSARP and LARP groups respectively (p=0.06). The median value of BFS was significantly lower in the PSARP group (PSARP=12.5, range: 8-18; LARP=16, range: 10-20, p=0.03). The median value of sphincteric resting pressure was 20mmHg (range: 10-50mmHg) in the PSARP group and 40mmHg (range: 10-70mmHg) in the LARP group (p=0.05). There was no significant difference in following measurements: the percentage of patient having a normal sphincteric resting pressure (PSARP vs LARP=50% vs 75%, p=0.28); the median sphincteric squeeze pressure (PSARP vs LARP=30mmHg, range: 10-100 vs 50mmHg, range: 20-140mmHg, p=0.08); the incidence of rectoanal inhibitory reflex (RAIR) (PSARP vs LARP=42.9% vs 31.3%, p=0.14) and the median value for volume of air to elicit the first anal sensation (PSARP vs LARP=30ml, range: 20-60ml vs 40ml, range: 20-80ml, p=0.18).

CONCLUSION

Anorectomanometry is a useful follow up study after anorectoplasty and majority of the patients with previous LARP could retain a normal sphincteric resting pressure during long term follow up. Comparing the two surgical approaches, patients with previous LARP could achieve a higher bowel function score as well as sphincter resting pressure in manometric assessment.

LEVEL OF EVIDENCE

Level III.

Laparoscopic posterior rectopexy (Well's procedure) for full-thickness rectal prolapse following laparoscopic repair of an anorectal malformation: A case report

•

Laparoscopic repair of intermediate anorectal malformation (ARM) lead to full-thickness rectal prolapse (RP) in a boy.

•

As conservative treatment modalities failed, the parents opted for surgical treatment at the patient’s age of 4 years.

•

Intractable RP of 2 cm with ulcerations was successfully treated by Well’s laparoscopic posterior mesh-rectopexy.

•

The mid-term outcome was favorable with no prolapse recurrence.

•

Well’s procedure represents a feasible treatment option for RP secondary to ARM repair in children.

Introduction

Intractable full-thickness rectal prolapse (IRP) unresponsive to conservative treatment remains a major problem after anorectoplasty for high or intermediate anorectal malformation (ARM). Surgical management must aim for a permanent fixation of the rectum to the presacral fascia. While in children with IRP following ARM repair the optimal procedure has not been established yet, laparoscopic posterior mesh-rectopexy (Well’s procedure) has demonstrated efficacy in adults.

Presentation of case

A male infant with intermediate ARM received laparoscopic-assisted anorectal pull-through at the age of 4 months. Three months later he developed mucosal prolapse and received multimodal conservative treatment. Because of progression into a full-thickness RP with ulcerations, the parents opted for surgical management. Well’s procedure was performed at the age of 4 years. Using four ports, the rectum was circumferentially mobilized down to the pelvic floor and pulled inside. A 5 × 5 cm prolene mesh was tacked to the sacrum, enveloped posteriorly 270° around the rectum, fixed with interrupted prolene sutures on both edges and carefully covered with peritoneum. Any redundant external mucosa was excised from a perineal approach. There were no intra- and postoperative complications. Within 1.5 years of follow-up the boy had voluntary bowel movements and was toilet trained. No prolapse recurrence could be observed nor provoked.

Discussion

We present the first pediatric case of IRP secondary to laparoscopic ARM repair which has been successfully treated by combined Well’s procedure and perineal mucosal resection.

Conclusion

Well’s procedure is a successful technique and should be further explored in children with ARM and IRP.

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.