Repair of low anorectal anomalies in female patients: risk factors for wound dehiscence

Percutaneous Anorectoplasty (PARP)—An Adaptable, Minimal-Invasive Technique for Anorectal Malformation Repair

Background: Anorectal malformations comprise a broad spectrum of disease. We developed a percutaneous anorectoplasty (PARP) technique as a minimal-invasive option for repair of amenable types of lesions. Methods: Patients who underwent PARP at five institutions from 2008 through 2021 were retrospectively analyzed. Demographic information, details of the operative procedure, and perioperative complications and outcomes were collected. Results: A total of 10 patients underwent the PARP procedure during the study interval. Patients either had low perineal malformations or no appreciable fistula. Most procedures were guided by ultrasound, fluoroscopy, or endoscopy. Median age at PARP was 3 days (range 1 to 311) days; eight patients were male. Only one intraoperative complication occurred, prompting conversion to posterior sagittal anorectoplasty. Functional outcomes in most children were highly satisfactory in terms of continence and functionality. Conclusions: The PARP technique is an excellent minimal-invasive alternative for boys born with perineal fistulae, as well as patients of both sexes without fistulae. The optimal type of guidance (ultrasound, fluoroscopy, or endoscopy) depends on the anatomy of the lesion and the presence of a colostomy at the time of repair.

Delayed vs. early enteral feeding after repair of congenital recto-vestibular fistula: The effect on perineal wound healing

INTRODUCTION

congenital Recto vestibular fistula represents the commonest type of anorectal malformation in females. The treatment of this anomaly is mainly approached either through anterior or posterior sagittal ano-rectoplasty approach. Several perioperative factors may affect the outcome. One of major postoperative complications is the occurrence of wound infection. We aimed to study the effect of delayed vs. early enteral feeding on the occurrence of perineal wound infection (PWI) after repair of congenital recto vestibular fistula.

PATIENTS AND METHODS

Fifty-five infants with recto-vestibular fistula were included. They were managed by single stage anterior sagittal anorectoplasty (ASARP) at an age ≥3 months. Groups A and B included infants who started oral intake on the 6th and 2nd postoperative days respectively. Group A infants were kept on peripheral parenteral nutrition (PPN) during the fasting period.

RESULTS

Superficial wound infection occurred in three cases in group A while it developed in seven cases in group B. Deep perineal infection occurred in two and five cases in group A and group B respectively. The mean hospital stay was 8 days in group A vs. 13 days in group B when PWI developed.

CONCLUSION

Delayed enteral feeding with PPN keeps the perineal wound less contaminated with stool. This promoted proper and fast healing with lower incidence of PWI. Also, PPN compensates the catabolic effects of both surgical trauma and fasting during the postoperative period and ensures maintenance of normal levels of essential nutrients that allow for proper healing.

Anorectal anomalies in the female: Highlights on surgical management

BACKGROUND

Anorectal anomalies (ARA) are characterized by different clinical presentations in both sexes with consequently different management protocols. There exist several controversies and different strategies to manage ARA in the female.

PURPOSE

To present our experience in managing girls with ARA highlighting the rationale behind the chosen protocol.

PATIENTS AND METHODS

The study included 121 girls with ARA who underwent sagittal anorectoplasty during the period 2009 through 2019. Their age ranged from 3 to 57 months (median = 7 months). There were 68 cases with rectoperineal fistula, 51 with rectovestibular fistula, 1 case with rectovaginal fistula and another case without fistula. Preoperative colostomy was performed in only 5 cases (3 rectovestibular; 1 rectovaginal; 1 without fistula). The rest of cases underwent delayed primary sagittal anorectoplasty (beyond the neonatal period).

RESULTS

Postoperative wound complications were detected in 14 cases (11.7%). In general, wound complications were more common among the rectoperineal group. Delayed healing problems in the form of mucosal prolapse/ectropion were detected in 10 cases. Thirty-four cases were available for delayed functional assessment. Voluntary bowel control was present in 91% of cases. Constipation was detected in 7 cases (20%) at follow up. Fecal soiling was present in 6 cases (17.6%); 3 of them were associated with constipation.

CONCLUSION

Delayed primary repair of rectoperineal and rectovestibular fistula is feasible with low complications. By adopting this protocol of management, we could achieve comparable results while avoiding unnecessary operations during the neonatal period.

LEVEL OF EVIDENCE

This is a case series (Level IV Evidence).

Vacuum-assisted closure (VAC) prevents wound dehiscence following posterior sagittal anorectoplasty (PSARP): An exploratory case-control study

BACKGROUND

Wound dehiscence (WD) of the anocutaneous anastomosis or perineal body after posterior sagittal anorectoplasty (PSARP) is common. We aimed to evaluate the efficacy of a perineal vacuum-assisted closure (VAC) for prevention of WD following repair of anorectal malformations (ARM) with rectoperineal and rectovestibular fistula.

METHODS

A retrospective dual-center case-control study of children undergoing PSARP without colostomy between 2011 and 2019 was performed. The VAC group received preoperative bowel preparation (PBP), postoperative application of a VAC, loperamide (only Location A), intravenous antibiotics (IA), and total parenteral nutrition (TPN). The non-VAC group underwent PBP, loperamide (Location A), IA, and TPN without VAC. Primary outcome was WD at the anocutaneous anastomosis or reconstructed perineal body within the first 14 days after surgery.

RESULTS

The study population included 18 patients (VAC group) and 20 children (non-VAG group) with rectoperineal and rectovestibular fistula. The incidence of WD in the VAC group was 0% compared to 25% in the non-VAC group (0/18 vs. 5/20, p = 0.04). No VAC related complications occurred.

CONCLUSION

Postoperative application of a VAC embedded in a perioperative treatment protocol has the potential to prevent wound dehiscence of the neoanus and reconstructed perineal body following PSARP.

TYPE OF STUDY

Case-control study.

LEVEL OF EVIDENCE

Level III.

Role of sagittal anorectoplasty in treating constipation in patients with recto-perineal fistula

Background

Recto-perineal fistula is a common anorectal anomaly, affecting both males and females. The anus is abnormally anteriorly located and is usually stenotic. Management of recto-perineal fistula is a dialectic problem. The most common presenting complaint is constipation; also, long-term follow-up of these patients revealed high incidence of postoperative constipation.

Results

The study included 30 patients (19 female and 11 male). Their age at time of repair ranged from 3 to 78 months. We compared the pre- and postoperative constipation rate after limited posterior sagittal anorectoplasty (PSARP) using Krickenbeck score. Overall, the rate of constipation has dropped from 77 (23/30) to 30% (9/30) after surgery. Fourteen patients out of 23 patients with preoperative constipation were cured. Another patient with preoperative constipation improved regarding the grade of constipation. The remaining 8 patients with preoperative constipation did not show improvement after operation. These results were statistically significant (McNemar test). Out of the 9 patients who were still constipated after surgery, 7 had associated fecal soiling that showed good response with bowel management of constipation.

Conclusion

Limited posterior sagittal anorectoplasty can have a role in treating constipation among cases of recto-perineal fistula.