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Wang K, Peng C, Pang W, Wang Z, Wu D, Chen Y. Long-term (> 10 years) bowel function of anorectal malformations: a retrospective single-center study. Pediatr Surg Int 2024; 40:138. [PMID: 38796646 DOI: 10.1007/s00383-024-05731-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/23/2024] [Indexed: 05/28/2024]
Abstract
PURPOSE To describe the long-term bowel function of anorectal malformation (ARM) patients and explore the potential influence factors. METHODS ARM patients with follow-up data > 10 years were included. Cases of cloaca, Currarino syndrome, and VACTERL syndrome were excluded. Rintala score and PedsQL 4.0 were used to assess bowel function score (BFS) and quality of life (QoL). Based on the results, patients were divided into satisfactory group with BFS ≥ 17 and unsatisfactory group with it < 17. Comparisons between the groups were made. RESULTS Among the 81 patients were 44 males and 37 females. Follow-up time was 138 (126,151) months. 16 (19.75%) patients had associated anomalies. 23 (28.40%) patients had reoperations, and fistula recurrence was the most common reason. BFS of the patients was 20 (18,20). QoL score was 100 (100,100), which correlated positively with BFS (r = 0.648, P < 0.001). The satisfactory and the unsatisfactory groups had 69 and 12 cases, and their BFS were 20 (20,20) and 11 (8,15) respectively, which had statistical difference (P < 0.001). Total QoL score and psycho-social health score of the unsatisfactory group were lower (P < 0.001). Only reoperations were statistically different between the groups (P < 0.001). CONCLUSIONS Long-term (> 10 years) bowel function of ARM patients is good in this study. Defecation problems have negative impacts on QoL and mainly affects their psycho-social health. Primary anorectoplasty is extremely important. Reoperations, which are most commonly seen in recto-urethral fistula recurrence, adversely affect the outcome.
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Affiliation(s)
- Kai Wang
- Department of General Surgery, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, No.56 Nanlishi st, Xicheng District, Beijing, 100045, China
| | - Chunhui Peng
- Department of General Surgery, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, No.56 Nanlishi st, Xicheng District, Beijing, 100045, China
| | - Wenbo Pang
- Department of General Surgery, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, No.56 Nanlishi st, Xicheng District, Beijing, 100045, China
| | - Zengmeng Wang
- Department of General Surgery, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, No.56 Nanlishi st, Xicheng District, Beijing, 100045, China
| | - Dongyang Wu
- Department of General Surgery, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, No.56 Nanlishi st, Xicheng District, Beijing, 100045, China
| | - Yajun Chen
- Department of General Surgery, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, No.56 Nanlishi st, Xicheng District, Beijing, 100045, China.
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Evans-Barns HME, Tien MY, Trajanovska M, Safe M, Hutson JM, Dinning PG, King SK. Post-Operative Anorectal Manometry in Children following Anorectal Malformation Repair: A Systematic Review. J Clin Med 2023; 12:jcm12072543. [PMID: 37048627 PMCID: PMC10094903 DOI: 10.3390/jcm12072543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 03/02/2023] [Accepted: 03/16/2023] [Indexed: 03/30/2023] Open
Abstract
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.
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Diao M, Li L, Ming AX, Yang CZ, Xie XH, Cheng W. Efficacy of Laparoscopic Management of Posterior Urethral Diverticulum in Anorectal Malformations. Eur Urol 2023; 83:55-61. [PMID: 36058802 DOI: 10.1016/j.eururo.2022.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 07/27/2022] [Accepted: 08/12/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND A posterior urethral diverticulum (PUD) is a serious postoperative complication after anorectal malformation correction. Complete resection is technical demanding because of limited retrourethral working space deep in the pelvis. OBJECTIVE We pioneered the single-incision laparoscopic approach for PUD excision and evaluated the efficacy. DESIGN, SETTING, AND PARTICIPANTS Twenty-six PUD patients undergoing redo surgeries between June 2011 and June 2021 were reviewed. SURGICAL PROCEDURE A series of transabdominal retraction sutures were placed through the PUD to facilitate dissection. The contents were evacuated to create a working space. Distal PUD dissection was carried along the submucosal layer to prevent injury of the urethra/pelvic nerve complex. The rectal mucosa was peeled off from the junction site for complete PUD excision. The muscular cuff of the distal rectum was then oversewn. MEASUREMENTS Operative time, postoperative recovery, and complications were assessed. RESULTS AND LIMITATIONS The mean age of redo surgery was 2.46 yr. The average operative duration was 2.35 h. The mean postoperative hospital stay, resumption of full diet, and bowel movement were 10.23, 2.15, and 1.54 d, respectively. The median follow-up period was 46 mo (12-132 mo). No remnant of PUD, recurrent fistula, or urinary leak was detected. None of the patients had difficulty in urination, urinary dribbling, urinary tract infection, constipation, or soiling. All patients retained morning erection, and two postpubertal patients had ejaculations. CONCLUSIONS Our single-incision laparoscopic redo surgery provides an effective approach for PUD excision. It minimizes complications. It also preserves urinary and bowel continence and sexual function. PATIENT SUMMARY Complete resection of a posterior urethral diverticulum (PUD) in anorectal malformation is technically demanding because of limited retrourethral working space in the deep pelvis. The outcomes of single-incision laparoscopic PUD excision were satisfactory.
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Affiliation(s)
- Mei Diao
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, PR China
| | - Long Li
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, PR China; Beijing Tsinghua Changgung Hospital, Beijing, PR China.
| | - An-Xiao Ming
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, PR China
| | - Chang-Zhen Yang
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, PR China
| | - Xiang-Hui Xie
- Department of Pediatric Urology, Capital Institute of Pediatrics, Beijing, PR China.
| | - Wei Cheng
- Chiron Healthcare Group, Hong Kong; Department of Surgery, Queen Mary Hospital, University of Hong Kong, Hong Kong.
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Zhao J, Zhang Y, Xiong Y, Du J, Chen Y, Guo W, Huang J. Three dimension high-definition manometry in evaluation of anorectal function in 104 normal infants and children: A clinical study from China. Neurogastroenterol Motil 2022; 34:e14395. [PMID: 35578443 DOI: 10.1111/nmo.14395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 03/15/2022] [Accepted: 04/11/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND We aimed to evaluate anorectal function of normal infants and children through three dimension high-definition anorectal manometry (3D ARM) to fill the research blank in this area. METHODS From November 2014 to January 2019, 104 normal infants and children among patients who underwent 3D ARM were divided into four groups according to age (≤1 month; >1 month to ≤1 year; >1 year to ≤4 years and >4 years) and reviewed. The following parameters were performed: the length of anorectal high-pressure zone (HPZ), the resting pressure of HPZ (HPZ-rest), the squeezing pressure of HPZ (HPZ-sqze), recto-anal inhibitory reflex (RAIR), and pressure distribution of the anal canal. Graphpad Prism 7.0 software was used for statistical analysis. RESULTS HPZ, HPZ-rest, and HPZ-sqze increased with age. There were differences in HPZ-rest and HPZ-sqze between the groups (p < 0.05). Sex had a significant effect on HPZ, but not on HPZ-rest and HPZ-sqze. The HPZ of males was higher than that of females among those ≤1 month old (p < 0.05). RAIR (-) was found in 17 patients (16%) for whom Hirschsprung's disease were excluded by biopsy, and these patients had regular defecation during follow-up. Most of the patients (85%) older than 1 year had a symmetric anal pressure distribution during the contracting period (p < 0.05). CONCLUSIONS Anal canal function parameters gradually increased with age in normal infants and children which demonstrated the important role of age in evaluation, and these parameters can provide a reference for postoperative evaluation of anal canal function.
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Affiliation(s)
- Jiawei Zhao
- Department of Neonatal Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Yanan Zhang
- Department of Neonatal Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Yu Xiong
- Department of Neonatal Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Jingbin Du
- Department of Neonatal Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Yongwei Chen
- Department of Neonatal Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Weihong Guo
- Department of Neonatal Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Jinshi Huang
- Department of Neonatal Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
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Miyake Y, Ochi T, Yamashiro Y, Seo S, Miyano G, Koga H, Lane GJ, Kuwatsuru R, Yamataka A. Levator ani asymmetry and deviation in high-type anorectal malformation evaluated by magnetic resonance imaging. Pediatr Surg Int 2022; 38:749-753. [PMID: 35235013 DOI: 10.1007/s00383-022-05104-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The levator ani (LA) complex in high-type imperforate anus (H-IA), low-type imperforate anus (L-IA), and Hirschsprung's disease (HD) patients as controls were documented using magnetic resonance imaging (MRI) and compared for symmetry. MATERIALS AND METHODS Mean left:right LA thickness ratio (LA ratio), and deviation of the LA from the pubococcygeal line (PCL; LA angle) were calculated from thin-slice MRI images (axial 2 mm, coronal 2 mm, and sagittal 3 mm) of the puborectalis and pubococcygeus taken parallel to the PCL under sedation in H-IA (n=14), L-IA (n=16), and HD (n=9). RESULTS MRI scans were performed between January 2018 and June 2021. LA were significantly thinner in H-IA (1.78±0.46 mm) compared with L-IA (2.97±0.55 mm) and controls (2.87±0.32 mm), p<0.0001. LA ratio was significantly lower in H-IA (0.71±0.15) compared with L-IA (0.93±0.04), and controls (0.91±0.06), p<0.0001. Mean LA-angle was significantly different in H-IA, 10.8° (range 6°-19°), versus L-IA and controls, both zero degrees (range 0°-5°), p<0.0001, respectively. CONCLUSIONS LA was confirmed to be significantly asymmetric in H-IA. Because outcome of surgical repair involving a midline incision, such as posterior sagittal anorectoplasty could be impaired, pediatric surgeons are advised to plan surgical intervention for H-IA carefully and appropriately.
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Affiliation(s)
- Yuichiro Miyake
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, 2-1-1 Hongo Bunkyo-ku, Tokyo, 113-8421, Japan.
| | - Takanori Ochi
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, 2-1-1 Hongo Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Yuki Yamashiro
- Department of Radiology, Juntendo University School of Medicine, 2-1-1 Hongo Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Shogo Seo
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, 2-1-1 Hongo Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Go Miyano
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, 2-1-1 Hongo Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Hiroyuki Koga
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, 2-1-1 Hongo Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Geoffrey J Lane
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, 2-1-1 Hongo Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Ryohei Kuwatsuru
- Department of Radiology, Juntendo University School of Medicine, 2-1-1 Hongo Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Atsuyuki Yamataka
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, 2-1-1 Hongo Bunkyo-ku, Tokyo, 113-8421, Japan
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Kiblawi R, Zoeller C, Zanini A, Kuebler JF, Dingemann C, Ure B, Schukfeh N. Laparoscopic versus Open Pediatric Surgery: Three Decades of Comparative Studies. Eur J Pediatr Surg 2022; 32:9-25. [PMID: 34933374 DOI: 10.1055/s-0041-1739418] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Despite its wide acceptance, the superiority of laparoscopic versus open pediatric surgery has remained controversial. There is still a call for well-founded evidence. We reviewed the literature on studies published in the last three decades and dealing with advantages and disadvantages of laparoscopy compared to open surgery. MATERIALS AND METHODS Studies comparing laparoscopic versus open abdominal procedures in children were searched in PubMed/MEDLINE. Reports on upper and lower gastrointestinal as hepatobiliary surgery and on surgery of pancreas and spleen were included. Advantages and disadvantages of laparoscopic surgery were analyzed for different types of procedures. Complications were categorized using the Clavien-Dindo classification. RESULTS A total of 239 studies dealing with 19 types of procedures and outcomes in 929,157 patients were analyzed. We identified 26 randomized controlled trials (10.8%) and 213 comparative studies (89.2%). The most frequently reported advantage of laparoscopy was shorter hospital stay in 60.4% of studies. Longer operative time was the most frequently reported disadvantage of laparoscopy in 52.7% of studies. Clavien-Dindo grade I to III complications (mild-moderate) were less frequently identified in laparoscopic compared to open procedures (80.3% of studies). Grade-IV complications (severe) were less frequently reported after laparoscopic versus open appendectomy for perforated appendicitis and more frequently after laparoscopic Kasai's portoenterostomy. We identified a decreased frequency of reporting on advantages after laparoscopy and increased reporting on disadvantages for all surgery types over the decades. CONCLUSION Laparoscopic compared with open pediatric surgery seems to be beneficial in most types of procedures. The number of randomized controlled trials (RCTs) remains limited. However, the number of reports on disadvantages increased during the past decades.
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Affiliation(s)
- Rim Kiblawi
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Christoph Zoeller
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany.,Department of Pediatric Surgery, University Hospital Munster, Munster, Nordrhein-Westfalen, Germany
| | - Andrea Zanini
- Department of Pediatric Surgery, Chris Hani Baragwanath Hospital, Johannesburg, South Africa
| | - Joachim F Kuebler
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Carmen Dingemann
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Benno Ure
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Nagoud Schukfeh
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
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Arbizu R, Freiberg B, Rodriguez L. Lower Gastrointestinal Functional and Motility Disorders in Children. Pediatr Clin North Am 2021; 68:1255-1271. [PMID: 34736588 DOI: 10.1016/j.pcl.2021.07.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Functional and motility gastrointestinal disorders are the most common complaints to the pediatric gastroenterologist. Disorders affecting the small intestine carry a significant morbidity and mortality due to the severe limitation of therapeutic interventions available and the complications associated with such interventions. Congenital colorectal disorders are rare but also carry significant morbidity and poor quality of life plus the social stigma associated with its complications. In this review, we summarize the clinical presentation, diagnostic evaluations, and the therapeutic interventions available for the most common and severe gastrointestinal functional and motility disorders of the small bowel, colon, and anorectum.
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Affiliation(s)
- Ricardo Arbizu
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Pediatric Gastroenterology and Hepatology, Neurogastroenterology and Motility Center, Yale School of Medicine, Yale University School of Medicine, Yale New Haven Children's Hospital, 333 Cedar Street, LMP 4093, PO Box 208064, New Haven, CT 06520, USA
| | - Ben Freiberg
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Pediatric Gastroenterology and Hepatology, Neurogastroenterology and Motility Center, Yale School of Medicine, Yale University School of Medicine, Yale New Haven Children's Hospital, 333 Cedar Street, LMP 4093, PO Box 208064, New Haven, CT 06520, USA
| | - Leonel Rodriguez
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Pediatric Gastroenterology and Hepatology, Neurogastroenterology and Motility Center, Yale School of Medicine, Yale University School of Medicine, Yale New Haven Children's Hospital, 333 Cedar Street, LMP 4093, PO Box 208064, New Haven, CT 06520, USA.
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Ieiri S, Ikoma S, Harumatsu T, Onishi S, Murakami M, Muto M, Kaji T. Trans-perineal transection through "Neo-Anus" for recto-bulbar urethral fistula using a 5-mm stapler in laparoscopically assisted anorectoplasty - A novel and secure technique. Asian J Endosc Surg 2021; 14:828-830. [PMID: 33749131 DOI: 10.1111/ases.12934] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 03/05/2021] [Accepted: 03/11/2021] [Indexed: 11/26/2022]
Abstract
Laparoscopically assisted anorectoplasty (LAARP) for recto-bulbar urethral fistula (RBUF) is not now a standard operation due to urethra injury risk and incomplete removal of fistula. Our approach is a novel and secure technique of trans-perineal transection using a 5-mm stapler for RBUF. Before performing LAARP, the orifice of RBUF was confirmed under flexible cystoscope inspection. Before transection of RBUF, the center of the muscle complex was detected at perineal skin. The muscle complex and the pubo-rectal sling were then also confirmed with electrical nerve stimulator under laparoscopic approach. A 5-mm trocar was inserted to pass through the center of the muscle complex from perineal incision of the neo-anus. RBUF was stapled and transected using a 5-mm stapler inserted from the neo-anus. The operator successfully confirmed complete adequate closure of RBUF under flexible cystoscope inspection. A 5-mm stapler was effective and useful for the transection of RBUF.
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Affiliation(s)
- Satoshi Ieiri
- Department of Pediatric Surgery, Research Field in Medical and Health Sciences, Medical and Dental Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Shinichiro Ikoma
- Department of Pediatric Surgery, Research Field in Medical and Health Sciences, Medical and Dental Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Toshio Harumatsu
- Department of Pediatric Surgery, Research Field in Medical and Health Sciences, Medical and Dental Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Shun Onishi
- Department of Pediatric Surgery, Research Field in Medical and Health Sciences, Medical and Dental Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Masakazu Murakami
- Department of Pediatric Surgery, Research Field in Medical and Health Sciences, Medical and Dental Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Mitsuru Muto
- Department of Pediatric Surgery, Research Field in Medical and Health Sciences, Medical and Dental Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Tatsuru Kaji
- Department of Pediatric Surgery, Research Field in Medical and Health Sciences, Medical and Dental Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan.,Clinical Training Center, Kagoshima University Hospital, Kagoshima, Japan
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Tirrell TF, McNamara ER, Dickie BH. Reoperative surgery in anorectal malformation patients. Transl Gastroenterol Hepatol 2021; 6:43. [PMID: 34423164 PMCID: PMC8343547 DOI: 10.21037/tgh-20-214] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 06/24/2020] [Indexed: 11/06/2022] Open
Abstract
Currently accepted primary repair of congenital anorectal malformations (ARMs) includes a posterior sagittal incision, which allows for optimal visualization and identification of important pelvic structures and anatomical features. Reconstructive surgery involves meticulous dissection and separation of pelvic structures, and careful reconstruction can result in good functional outcomes for many patients, who live without ongoing sequelae from their malformation. However, some patients may require reoperative procedures for anatomic or functional reasons. Males and females present with slightly different symptoms and should be approached differently. Males are most likely to require reoperations for anorectal or urethral pathologies, but the urinary system is often spared in females-they instead must contend with Mullerian duct anomalies, of which there are many varieties. Depending on the original malformation and severity of symptoms, redo surgery may be needed to optimize function and quality of life. Surgical management with reoperative surgery in ARMs ranges from straightforward to complex, depending on the issue. One must weigh the risks of reoperative surgery and potentially creating more scarring against the need for a better anatomical and functional outcome. Current management trends and practice patterns with regards to reoperative surgery in ARM patients are not widely studied or standardized but we provide an overview of the more common pathologies, preoperative evaluation and workup required to identify the issues, and options for reoperative repair in these patients.
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Affiliation(s)
| | - Erin R McNamara
- Department of Urology, Boston Children's Hospital, Boston, MA, USA
| | - Belinda H Dickie
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
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Ishimaru T, Kawashima H, Hayashi K, Omata K, Sanmoto Y, Inoue M. Laparoscopically assisted anorectoplasty-Surgical procedures and outcomes: A literature review. Asian J Endosc Surg 2021; 14:335-345. [PMID: 33029900 DOI: 10.1111/ases.12877] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/08/2020] [Accepted: 09/22/2020] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Tetsuya Ishimaru
- Division of Pediatric Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Hiroshi Kawashima
- Division of Pediatric Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Kentaro Hayashi
- Division of Pediatric Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Kanako Omata
- Division of Pediatric Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Yohei Sanmoto
- Division of Pediatric Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Maho Inoue
- Division of Pediatric Surgery, Saitama Children's Medical Center, Saitama, Japan
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A novel combined enteroscopy and laparoscopy approach to prevent urethral complications in management of rectourethral fistula. Surg Endosc 2021; 35:1921-1926. [PMID: 33523272 DOI: 10.1007/s00464-020-08268-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 12/22/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND For the last 20 years, laparoscopy management of anorectal malformations (ARM) has been challenged due to the development of postoperative urethral diverticulum or injury caused by the imprecise transection of rectourethral fistulae, particularly rectobulbar fistulae situated deep in the pelvis. We have developed a combined approach of enteroscopy and laparoscopy for intraluminal incision of a rectourethral fistula. METHODS We retrospectively reviewed 47 ARM patients who underwent surgical corrections using the combined approach between January 2019 and June 2020. Early postoperative and subsequent follow-up results were evaluated. RESULTS The median follow-up period was 12 months. The average age at surgery was 3.18 ± 0.64 months. The mean operative time of a single-incision laparoscopic-assisted anorectoplasty (SILAARP) was 1.19 ± 0.29 h. The time for intraluminal incision of the fistula was shortened from 14 to 2 min. No patients underwent a conversion. The average postoperative hospital stay, time to full feeds and placement of an anal tube were 10 days, 1 day, and 5 days, respectively. No urethral diverticulum, urinary injury, wound infection, rectal retraction, anal stenosis or rectal prolapse was encountered in the cohort. CONCLUSIONS The combined enteroscopy and laparoscopy approach offers precise management of rectourethral fistulae. It could effectively obviate urethral complications, eliminating the obstacles of laparoscopy application in the management of ARMs.
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Li L, Ren X, Ming A, Xu H, Sun R, Zhou Y, Liu X, Sun H, Li Q, Li X, Zhang Z, Cheng W, Diao M, Tam PKH. Laparoscopic surgical technique to enhance the management of anorectal malformations: 330 cases' experience in a single center. Pediatr Surg Int 2020; 36:279-287. [PMID: 31919580 DOI: 10.1007/s00383-019-04614-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/29/2019] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Long Li
- Department of Pediatric Surgery, Capital Institute of Pediatrics, No. 2 Yabao Road, Chaoyang District, Beijing, 100020, People's Republic of China.
| | - Xianghai Ren
- Department of Pediatric Surgery, Capital Institute of Pediatrics, No. 2 Yabao Road, Chaoyang District, Beijing, 100020, People's Republic of China.,Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, People's Republic of China
| | - Anxiao Ming
- Department of Pediatric Surgery, Capital Institute of Pediatrics, No. 2 Yabao Road, Chaoyang District, Beijing, 100020, People's Republic of China
| | - Hang Xu
- Department of Pediatric Surgery, Capital Institute of Pediatrics, No. 2 Yabao Road, Chaoyang District, Beijing, 100020, People's Republic of China
| | - Rui Sun
- Department of Pediatric Surgery, Capital Institute of Pediatrics, No. 2 Yabao Road, Chaoyang District, Beijing, 100020, People's Republic of China.,Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, People's Republic of China
| | - Yan Zhou
- Department of Pediatric Surgery, Capital Institute of Pediatrics, No. 2 Yabao Road, Chaoyang District, Beijing, 100020, People's Republic of China.,Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, People's Republic of China
| | - Xuelai Liu
- Department of Pediatric Surgery, Capital Institute of Pediatrics, No. 2 Yabao Road, Chaoyang District, Beijing, 100020, People's Republic of China
| | - Hailin Sun
- Department of Medical Imaging, Capital Institute of Pediatrics, Beijing, 100020, People's Republic of China
| | - Qi Li
- Department of Pediatric Surgery, Capital Institute of Pediatrics, No. 2 Yabao Road, Chaoyang District, Beijing, 100020, People's Republic of China
| | - Xu Li
- Department of Pediatric Surgery, Capital Institute of Pediatrics, No. 2 Yabao Road, Chaoyang District, Beijing, 100020, People's Republic of China
| | - Zhen Zhang
- Department of Pediatric Surgery, Capital Institute of Pediatrics, No. 2 Yabao Road, Chaoyang District, Beijing, 100020, People's Republic of China
| | - Wei Cheng
- Department of Pediatrics, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Australia.,New Century Healthcare, Hong Kong, People's Republic of China
| | - Mei Diao
- Department of Pediatric Surgery, Capital Institute of Pediatrics, No. 2 Yabao Road, Chaoyang District, Beijing, 100020, People's Republic of China.
| | - Paul K H Tam
- Dr. Li Dak Sum Research Centre, The University of Hong Kong, Hong Kong, People's Republic of China
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Abstract
PURPOSE We investigated the anorectal musclulature in normal children and anorectal malformations (ARM) to evaluate its role in bowel control mechanism. METHODS Pelves of 50 neonates died of ARM-unrelated diseases and 16 patients with anorectal malformations (8 high, 5 intermediate, and 3 low ARMs) were dissected and analyzed. RESULTS Normal anorectal musculature was divided into three muscular tubes: the internal sphincter tube (IAST), longitudinal muscle tube (LMT) and transverse muscle tube (TMT). The LMT came from the outer longitudinal smooth muscle fiber of the rectum and the striated muscle fiber of the levator ani, and the TMT composed of the puborectalis and the external anal sphincter. However, in ARM, the IAST was absent and the LMT, the center of the sphincter muscle complex, was only from the levator ani and could be divided into the pelvic portion and the perineal portion. The former, from the upper rim of the puborectalis to the bulbar urethral, became narrowed and dislocated anteriorly near to the posterior urethra in high ARM and rectal pouch in intermediate ARM. The latter, below the bulbar urethra to the anal dimple, was fused to a column both in high and intermediate ARM. The columnar perineal LMT run downwards and then split, penetrated the superficial part of EAS and terminated at the deep aspect of the skin, to form the anal dimple, which represents the center of the perineal LMT from the perineal aspect. The length of the LMT was longer in high and intermediate ARM than the normal neonate. The columnar perineal LMT and narrowed pelvic LMT could be possibly identified by laparoscopic and perineal approaches retrospectively and widened to allow the passage of the rectum through. CONCLUSIONS The anorectal musculature in ARM is composed of agenesic LMT and TMT and the narrowed LMT gives anatomical evidence of the center, where the neorectum should pull through.
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Peña A, Bealer J, Bischoff A. Re: "Assessing the long term manometric outcomes in patients with previous laparoscopic anorectoplasty (LARP) and posterior sagittal anorectoplasty (PSARP)" by Chung, et al. JPS. Vol. 53, no. 10 October 2018 pp1933-1936. J Pediatr Surg 2019; 54:1262. [PMID: 30851957 DOI: 10.1016/j.jpedsurg.2018.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 11/30/2018] [Indexed: 11/24/2022]
Affiliation(s)
- Alberto Peña
- International Center for Colorectal and Urogenital Care, Department of Pediatric Surgery, Children's Hospital Colorado, Aurora-CO.
| | - John Bealer
- International Center for Colorectal and Urogenital Care, Department of Pediatric Surgery, Children's Hospital Colorado, Aurora-CO
| | - Andrea Bischoff
- International Center for Colorectal and Urogenital Care, Department of Pediatric Surgery, Children's Hospital Colorado, Aurora-CO
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