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Smith CA, Rialon KL, Kawaguchi A, Dellinger MB, Goldin AB, Acker S, Kulaylat AN, Chang H, Russell K, Wakeman D, Derderian SC, Englum BR, Polites SF, Lucas DJ, Ricca R, Levene TL, Sulkowski JP, Kelley-Quon LI, Tashiro J, Christison-Lagay ER, Mansfield SA, Beres AL, Huerta CT, Ben Ham P, Yousef Y, Rentea RM. Classification and Surgical Management of Anorectal Malformations: A Systematic Review and Evidence-based Guideline From the APSA Outcomes and Evidence-based Practice Committee. J Pediatr Surg 2024:S0022-3468(24)00365-8. [PMID: 38997855 DOI: 10.1016/j.jpedsurg.2024.06.007] [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: 01/25/2024] [Revised: 06/03/2024] [Accepted: 06/09/2024] [Indexed: 07/14/2024]
Abstract
OBJECTIVE Treatment of neonates with anorectal malformations (ARMs) can be challenging due to variability in anatomic definitions, multiple approaches to surgical management, and heterogeneity of reported outcomes. The purpose of this systematic review is to summarize existing evidence, identify treatment controversies, and provide guidelines for perioperative care. METHODS The American Pediatric Surgical Association Outcomes and Evidence Based Practice Committee (OEBP) drafted five consensus-based questions regarding management of children with ARMs. These questions were related to categorization of ARMs and optimal methods and timing of surgical management. A comprehensive search strategy was performed, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to perform the systematic review to attempt to answer five questions related to surgical care of ARM. RESULTS A total of 10,843 publications were reviewed, of which 90 were included in final recommendations, and some publications addressed more than one question (question: 1 n = 6, 2 n = 63, n = 15, 4 n = 44). Studies contained largely heterogenous groups of ARMs, making direct comparison for each subtype challenging and therefore, no specific recommendation for optimal surgical approach based on outcomes can be made. Both loop and divided colostomy may be acceptable methods of fecal diversion for patients with a diagnosis of anorectal malformation, however, loop colostomies have higher rates of prolapse in the literature reviewed. In terms of timing of repair, there did not appear to be significant differences in outcomes between early and late repair groups. Clear and uniform definitions are needed in order to ensure similar populations of patients are compared moving forward. Recommendations are provided based primarily on A-D levels of evidence. CONCLUSIONS Evidence-based best practices for ARMs are lacking for many aspects of care. Multi-institutional registries have made progress to address some of these gaps. Further prospective and comparative studies are needed to improve care and provide consensus guidelines for this complex patient population. LEVEL OF EVIDENCE: 3
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Affiliation(s)
- Caitlin A Smith
- Department of General Surgery, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA 98105, USA.
| | - Kristy L Rialon
- Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Akemi Kawaguchi
- Department of Pediatric Surgery, McGovern Medical School at the Unversity of Texas Health Science Center at Houston, Houston, TX, USA
| | - Matthew B Dellinger
- Department of General Surgery, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA 98105, USA
| | - Adam B Goldin
- Department of General Surgery, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA 98105, USA
| | | | - Afif N Kulaylat
- Penn State Children's Hospital, Division of Pediatric Surgery, Hershey, PA, USA
| | - Henry Chang
- Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Katie Russell
- University of Utah Health, Primary Children's Hospital, Salt Lake City, UT, USA
| | | | | | - Brian R Englum
- University of Maryland Children's Hospital, Baltimore, MD, USA
| | | | - Donald J Lucas
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA; Naval Medical Center San Diego, CA, USA
| | - Robert Ricca
- University of South Carolina, Greenville, SC, USA
| | | | | | | | - Jun Tashiro
- Hassenfeld Children's Hospital at NYU Langone Health, New York, NY, USA
| | | | | | - Alana L Beres
- St. Christopher's Hospital for Children, Philadelphia PA, USA
| | | | - P Ben Ham
- University at Buffalo, John R. Oishei Children's Hospital, Buffalo, NY, USA
| | - Yasmine Yousef
- McGill University, Montreal Children's Hospital, Montreal, QC, USA
| | - Rebecca M Rentea
- Department of Surgery, Children's Mercy Hospital, University of Missouri-Kansas City, 2401 Gillham Rd, Kansas City, MO 64108, USA
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Caruso AM, Bommarito D, Girgenti V, Amato G, Calabrese U, Figuccia A, Baldanza F, Grasso F, Giglione E, Casuccio A, Milazzo MPM, Di Pace MR. Evaluation of Anal Sphincter with High Resolution Anorectal Manometry and 3D Reconstruction in Patients with Anorectal Malformation. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1037. [PMID: 37371268 DOI: 10.3390/children10061037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 05/27/2023] [Accepted: 06/01/2023] [Indexed: 06/29/2023]
Abstract
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.
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Affiliation(s)
- Anna Maria Caruso
- Pediatric Surgical Unit, Children's Hospital 'G. di Cristina', ARNAS Civico, 90100 Palermo, Italy
| | - Denisia Bommarito
- Pediatric Surgical Unit, Children's Hospital 'G. di Cristina', ARNAS Civico, 90100 Palermo, Italy
| | - Vincenza Girgenti
- Pediatric Surgical Unit, Children's Hospital 'G. di Cristina', ARNAS Civico, 90100 Palermo, Italy
| | - Glenda Amato
- Pediatric Surgical Unit, Children's Hospital 'G. di Cristina', ARNAS Civico, 90100 Palermo, Italy
| | - Ugo Calabrese
- Pediatric Surgical Unit, Children's Hospital 'G. di Cristina', ARNAS Civico, 90100 Palermo, Italy
| | - Adele Figuccia
- Pediatric Surgical Unit, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialities, University of Palermo, 90100 Palermo, Italy
| | - Fabio Baldanza
- Pediatric Surgical Unit, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialities, University of Palermo, 90100 Palermo, Italy
| | - Francesco Grasso
- Pediatric Surgical Unit, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialities, University of Palermo, 90100 Palermo, Italy
| | - Emanuela Giglione
- Pediatric Surgery Division, Women's and Children's Health Department, University of Padua, 35100 Padua, Italy
| | - Alessandra Casuccio
- Pediatric Surgical Unit, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialities, University of Palermo, 90100 Palermo, Italy
| | | | - Maria Rita Di Pace
- Pediatric Surgical Unit, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialities, University of Palermo, 90100 Palermo, Italy
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AbouZeid AA, Mohammad SA, Shokry SS, El-Naggar O. Posterior cloaca: A urogenital rather than anorectal anomaly. J Pediatr Urol 2021; 17:410.e1-410.e7. [PMID: 33549475 DOI: 10.1016/j.jpurol.2021.01.014] [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: 11/05/2020] [Revised: 01/04/2021] [Accepted: 01/14/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND 'Persistent Cloaca' refers to one of the major groups of anorectal anomalies in the female when a single perineal orifice is located at the normal site of the urethra draining both urogenital and alimentary tracts. However, 'posterior cloaca' is a new term developed by Pena to describe a unique defect in females in which a common urogenital sinus is deviated posteriorly to open into normally located anorectum (type A) or in the perineum slightly anterior to the anus (type B). METHODS The study included seven girls diagnosed as posterior cloaca. Their age at presentation ranged from 1 to 108 months (median 12 months). The main presentation was abnormal external genitalia, while two cases underwent colostomy (±vaginostomy) at birth. Surgical reconstruction varied according to the degree of deviation from normal anatomy. Partial urogenital sinus mobilization (PUM) was used to correct minor forms; while at the other end of the spectrum (absent urinary bladder), continent urinary diversion was performed. Due to the high incidence of renal and urological anomalies, regular follow up at paediatric nephrology/urology clinics was advised for affected cases. RESULTS All seven cases had a common urogenital confluence characteristically deviated posteriorly. The degree of backward deviation of the common urogenital orifice was variable ranging from mild to severe posterior displacement. In six cases (85%), the common urogenital orifice was shifted backwards in the perineum approaching the anal verge (type B). In one case, the common urogenital orifice opened internally into the anorectum (type A). Major urinary tract anomalies were quite common (5 of 7 cases; 71%): absent urinary bladder (2 cases); single kidney (2 cases); crossed ectopic kidney (1 case); hydroureteronephrosis (2 cases). CONCLUSION Posterior cloaca is a rare anomaly in the female essentially affecting the lower urogenital tract with a high incidence of associated renal anomalies. Management should be tailored according to the degree of developmental defect.
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Affiliation(s)
| | | | - Shady S Shokry
- Pediatric Surgery Department, Faculty of Medicine, Ain Shams University, Egypt
| | - Osama El-Naggar
- Pediatric Surgery Department, Faculty of Medicine, Ain Shams University, Egypt
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