Anorectal malformations

Anorectal Malformations and Hirschsprung Disease: A 30-Year Retrospective Outreach Review

Objective This study analyses the indications for and outcomes of primary and redo surgeries for anorectal malformations (ARMs) and Hirschsprung disease (HD) in developing, resource-limited countries. The study seeks to identify trends in primary surgery complication rates, evaluate the indications for reoperation and explore potential strategies to improve surgical management and long-term outcomes for children with ARM and HD in these settings. Methodology A retrospective cohort analysis was conducted on data collected by the Kind Cut for Kids (KCFK) surgical outreach program, a charitable initiative that provides paediatric surgical care in under-served regions. Data was collected over a 30-year period across 22 developing countries. The dataset contained 2,498 observations linked to ARM or HD, which was filtered to include those with primary surgeries, reoperations for prior complications and management of complications of any surgery done by the visiting team. Clinical data included demographics, pathology classification, surgical details, and postoperative outcomes. Results The final cohort included 496 ARM patients and 224 HD patients, with 65% and 41%, respectively, undergoing primary corrective surgeries. Among ARM cases, 25% required redo surgeries, with malposition (33%), strictures (24%), or prolapse (8%) being the most common indications. In HD, 45% of patients required redo procedures, primarily for strictures (19%), prolapse (9%), or acquired fistulas (4%). The most common redo procedures for ARMs were the posterior sagittal anorectoplasty (PSARP) (58%) or anorectal angle plication (10%). For HD patients, PSARP (11%) and the Swenson procedure (10%) were the most common corrective redo procedures. Due to the focus of KCFK visits, there are significant data gaps pertaining to primary surgical details, reoperation indications and follow-up data. This reflects the challenges of managing these conditions in resource-limited environments and with an outreach program. Conclusion This study highlights high rates of complications from primary surgeries in ARM and HD cases treated in resource-limited settings, which emphasises the need for enhanced surgical precision, structured postoperative care, and consistent follow-up protocols, as well as education of surgeons in the countries visited. Targeted interventions such as capacity-building initiatives, tailored consensus guidelines, and telemedicine integration are critical to addressing disparities in care. Future prospective studies with standardised data collection and outcome metrics are essential to validate these findings and improve care delivery for children with ARM and HD in underserved regions.

H-type Rectovestibular Fistula Presenting as a Left Labial Abscess: A Diagnostic Masquerade

Anorectal malformations (ARMs) is a congenital abnormality that is commonly seen in newborns without a normal or ectopic anal opening. H-type fistula is a rare subtype and is commonly diagnosed in females after a history of passing stool from the vagina which may be the first and only sign of an underlying ARM which necessitates further diagnostic modalities, treatment, and follow-up. These children may have a normal anal opening. We report on a rare case of rectovaginal fistula presenting with a left labial abscess.

Adult Obstetricians and Gynecologists Lack Knowledge of Anorectal Malformations-A Call for Action

OBJECTIVE

Patients with anorectal malformations (ARMs) may have concurrent gynecologic abnormalities. As patients grow, they typically transition from pediatric subspeciality care and seek adult obstetrics and gynecology (OB/GYN)-related services. We aimed to assess adult OB/GYN physicians' knowledge, competency, and comfort regarding meeting the sexual and reproductive health care needs of patients with ARMs.

METHODS

We performed a cross-sectional observational survey-based study of graduates from a single academic OB/GYN residency program from 2013 to 2022. Physicians were surveyed on experience, comfort, and challenges with caring for patients with ARMs and given a knowledge assessment. Descriptive and comparative statistics between those who did and did not complete a Pediatric and Adolescent Gynecology (PAG) rotation were generated.

RESULTS

There were 59 respondents (53.6%). Fewer than half (39.0%) reported caring for a patient with an ARM, an appendicovesicostomy (12.3%), or an appendicostomy (5.4%). Most felt uncomfortable (80.4%) or felt they lacked competence in caring for these patients (81.8%). Most (64.3%) felt that ARMs should be discussed in residency. Only 1 physician (1.7%) answered all questions in the knowledge assessment correctly; 33.9% did not answer any question correctly. On subgroup analysis, more physicians who had completed a pediatric and adolescent gynecology rotation recalled learning about ARMs (83.3% vs 51.9%, P = .03); however, there were no differences in experience, comfort, competence, or willingness to learn.

CONCLUSION

OB/GYN providers report a lack of knowledge and comfort in caring for patients with ARMs. Development of a standardized OB/GYN residency curriculum and education for practicing OB/GYN physicians is necessary to allow access to knowledgeable sexual and reproductive health for this patient population.

[Mitoxantrone hydrochloride liposome combined with cytarabine for treating pediatric acute myeloid leukemia with RUNX1∷MTG16 fusion gene: a case report and literature review]

This case report presents a patient with pediatric acute myeloid leukemia (AML) with RUNX1∷MTG16, admitted to the Blood Disease Hospital of the Chinese Academy of Medical Sciences in October 2023. He was 13 years old, with a chief complaint of fatigue for 20 days. Bone marrow smear revealed 17.0% blasts, the karyotype was 46,XY,t (16; 21) (q24; q22), molecular biology demonstrated RUNX1∷MTG16 fusion gene, combined with FLT3-ITD mutation. The child was diagnosed with AML (with RUNX1 ∷ MTG16). Complete remission was achieved after chemotherapy induction. The induction therapy regimen was mitoxantrone hydrochloride liposomes combined with cytarabine (MA). The RUNX1 ∷ MTG16 and FLT3-ITD were negative after another MA treatment course. However, the RUNX1 ∷ MTG16 and FLT3-ITD were turning positive during the following intensive treatment, and he then successfully underwent matched sibling donor umbilical cord blood transplantation.

Primary Anterior Sagittal Anorectoplasty Shift from Staged to Single-stage Procedure for Low Anorectal Malformations in Female Children: Our Initial Experience in Single Centre

BACKGROUND

Anorectal malformation (ARM) is a common congenital anomaly found in the paediatric age group. Previously, the repair of the vestibular fistula (VF) was performed as three-stage procedure with initial colostomy followed by a definite procedure and, lastly, colostomy closure. At present, a single-stage procedure is preferred, especially in lower anomalies owing to the convenient and time-saving approach.

OBJECTIVE

The clinical profile and outcome of ASARP for treatment of ARM in females (vestibular anus and perineal fistula).

METHODS

A retrospective analytical study was conducted at Government Medical College, Jammu. A total of 60 patients were included in the study.

RESULTS

Most of the patients were in the age group of 1-5 years (30%), followed by 6 months-1 year age group (25%). Forty-five (75%) females had VF while 15 (25%) had perineal fistula. Intraoperative complication was vaginal tear seen in 6 (10%) patients followed by rectal tear seen in 3 (5%) patients. Early post-operative complications were seen in 9 (15%) patients. Wound infection was the most common complication seen in 5 (8.3%) patients, wound dehiscence in 3 (5%) patients and retraction of rectum in 1 (1.6%) patient. Late post-operative complications were seen in 24 (40%) patients. Perineal excoriation was the most common complication seen in 6 (10%) patients, constipation seen in 5 (8.3%) patients, anal stenosis in 4 (6.6%) patients and mucosal prolapse in 4 (6.6%) patients.

CONCLUSION

The single-staged ASARP procedure resulted in satisfactory outcomes. It is an excellent procedure for females with VF and perineal fistula. Appropriate selection, preparation of patient, optimal correction with minimal sphincter damage and needful post-operative care of wound give excellent cosmetic and functional outcomes in terms of continence. It also decreases the burden on treating the surgeon, family and psychological stress on the patients and parents.

Comparison of total prevalence, perinatal prevalence, and livebirth prevalence of birth defects in Hunan Province, China, 2016-2020

Objective

Birth defect of any type is undesirable and often pose a negative impact on the health and development of the newborn. Birth defects surveillance with datasets from surveillance health-related programs are useful to predict the pattern of birth defects and take preventive measures. In this study, the total prevalence, perinatal prevalence, and livebirth prevalence of birth defects were compared.

Methods

Data were obtained from the Birth Defects Surveillance System in Hunan Province, China, 2016-2020. The total prevalence is the number of birth defects (including livebirths, stillbirths, and selective terminations of pregnancy) per 1,000 births (including livebirths and stillbirths). The perinatal prevalence is the number of birth defects (between 28 weeks gestation and 7 days postpartum) per 1,000 births. The livebirth prevalence is the number of liveborn birth defects per 1,000 births (unit: ‰). Underestimated proportion (unit: %) is the reduction level of perinatal prevalence or livebirth prevalence compared to the total prevalence. Prevalence with 95% confidence intervals (CI) was calculated using the log-binomial method. Chi-square tests (χ 2) were used to examine if significant differences existed in prevalence or underestimated proportion between different groups.

Results

A total of 847,755 births were included in this study, and 23,420 birth defects were identified, including 14,459 (61.74%) birth defects with gestational age > =28 weeks, and 11,465 (48.95%) birth defects in livebirths. The total prevalence, perinatal prevalence, and livebirth prevalence of birth defects were 27.63‰ (95%CI, 27.27-27.98), 17.06‰ (95%CI, 16.78-17.33), and 13.52‰ (95%CI, 13.28-13.77), respectively, and significant differences existed between them (χ2  = 4798.55, p < 0.01). Compared to the total prevalence, the perinatal prevalence and livebirth prevalence were underestimated by 38.26 and 51.05%, respectively. Significant differences existed between the total prevalence, perinatal prevalence, and livebirth prevalence of birth defects in all subgroups according to year, sex, residence, and maternal age (p < 0.05). Significant differences existed between the total prevalence, perinatal prevalence, and livebirth prevalence for 17 specific defects: congenital heart defect, cleft lip-palate, Down syndrome, talipes equinovarus, hydrocephalus, limb reduction, cleft lip, omphalocele, anal atresia, anencephaly, spina bifida, diaphragmatic hernia, encephalocele, gastroschisis, esophageal atresia, bladder exstrophy, and conjoined twins (p < 0.05). In comparison, no significant difference existed between the total prevalence, perinatal prevalence, and livebirth prevalence for 6 specific defects: polydactyly, other external ear defects, syndactyly, hypospadias, cleft palate, and anotia/microtia (p > 0.05).

Conclusion

The total prevalence and livebirth prevalence of birth defects in Hunan Province, China, was not well studied. A systematic study was conducted to compare the total prevalence, perinatal prevalence, and livebirth prevalence of birth defects. The study reveals that significant differences existed between the total prevalence, perinatal prevalence, and livebirth prevalence of birth defects (including many specific defects), and year, sex, residence, and maternal age had significant impacts on it. The outcomes of the study will help to take preventive measures for birth defects as well as benefit the people involving public health and policymakers to improve the current scenario.

Expanding the clinical spectrum of Coffin-Siris syndrome with anorectal malformations: Case report and review of the literature

Anorectal malformations (ARMs) represent a wide spectrum of congenital anomalies of the anus and rectum, of which more than half are syndromic. Their etiology is highly heterogeneous and still poorly understood. We report a 4-year-old girl who initially presented with an isolated ARM, and subsequently developed a global developmental delay as part of an ARID1B-related Coffin-Siris syndrome (CSS). A co-occurrence of ARMs and CSS in an individual by chance is unexpected since both diseases are very rare. A review of the literature enabled us to identify 10 other individuals with both CSS and ARMs. Among the ten individuals reported in this study, 8 had a variant in ARID1A, 2 in ARID1B, and 1 in SMARCA4. This more frequent than expected association between CSS and ARM indicates that some ARMs are most likely part of the CSS spectrum, especially for ARID1A-related CSS.

Management and outcomes of vestibular anorectal malformations in a low-income country hospital

Introduction

anorectal malformations (ARM) are among the most common congenital anomalies in pediatric surgery. Early detection and management of vestibular fistulas are crucial for optimal outcomes, capitalizing on the pliability of sphincter muscles and the preservation of somatosensory integration. This study aimed to assess the incidence, clinical presentation, and management outcomes of vestibular fistula ARM in a low-income hospital setting.

Methods

a retrospective audit was conducted on female pediatric patients aged up to 12 years treated for vestibular fistula ARM from January 1, 2011, to June 30, 2016. Data were collected from medical records, and patients were categorized into one of three surgical management groups. Clinical assessments, preoperative procedures, and surgical interventions were meticulously documented.

Results

among 656 neonates, the incidence of vestibular fistula ARM was 8.2%. Patients presented at various ages, with 69.4% being early presenters. Notably, 11.1% of cases presented after 30 weeks of age. Functional fistula, constipation, and bowel obstruction were common presenting symptoms. Associated anomalies were relatively low. The choice of surgical approach varied, with a predominant 3-stage at 68%. Complication development did not significantly differ between surgical groups (p-value 0.083). Immediate postoperative complications were minimal, but complications at definitive anoplasty varied among the surgical groups. Anal strictures and fistula recurrence were noted. At 12 months post-surgery, anal strictures persisted in 9 participants.

Conclusion

this study highlights the challenges and outcomes associated with vestibular fistula ARM in a resource-constrained setting. The 3-stage approach, despite its historical preference, demonstrated suboptimal outcomes. A 2-stage procedure appears to offer a balanced alternative, particularly suitable for low-income healthcare systems. Further research and collaborative efforts are essential to refine the management of vestibular fistula ARM and improve patient outcomes.

Update from a cohort study for birth defects in Hunan Province, China, 2010-2020

To define the relationship between sex, residence, maternal age, and a broad range of birth defects by conducting a comprehensive cross-analysis based on up-to-date data. Data were obtained from the Birth Defects Surveillance System in Hunan Province, China, 2010-2020. Prevalences of birth defects (number of cases per 10,000 fetuses (births and deaths at 28 weeks of gestation and beyond)) with 95% confidence intervals (CI) were calculated by sex, residence, maternal age, year, and 23 specific defects. Cross-analysis of sex, residence, and maternal age was conducted, and crude odds ratios (ORs) were calculated to examine the association of each maternal characteristic with birth defects. A total of 1,619,376 fetuses and 30,596 birth defects were identified. The prevalence of birth defects was 188.94/10,000 (95% CI 186.82-191.05). Birth defects were more frequent in males than females (210.46 vs. 163.03/10,000, OR = 1.30, 95% CI 1.27-1.33), in urban areas than in rural areas (223.61 vs. 162.90/10,000, OR = 1.38, 95% CI 1.35-1.41), and in mothers ≥ 35 than mothers 25-29 (206.35 vs. 187.79/10,000, OR = 1.10, 95% CI 1.06-1.14). Cross-analysis showed that the prevalence of birth defects was higher in urban females than in rural males (194.53 vs. 182.25/10,000), the difference in prevalence between males and females was more significant for maternal age < 20 compared to other age groups (OR = 1.64, 95% CI 1.37-1.95), and the prevalence difference between urban and rural areas is more significant for maternal age 25-34 compared to other age groups (OR = 1.49, 95% CI 1.43-1.57). Cleft palates were more frequent in males, and nine specific defects were more frequent in females. Five specific defects were more frequent in rural areas, and eight were more frequent in urban areas. Compared to mothers 25-29, five specific defects were more frequent in mothers < 20, seven specific defects were more frequent in mothers 20-24, two specific defects were more frequent in mothers 30-34, and ten specific defects were more frequent in mothers ≥ 35. Our data indicate that sex, residence, and maternal age differences in the prevalences of birth defects and most specific defects are common. We have found some new epidemiological characteristics of birth defects using cross-analysis, such as residence is the determining factor for the prevalence of birth defects, the difference in prevalence between males and females was more significant for maternal age < 20 compared to other age groups, the prevalence difference between urban and rural areas is more significant for maternal age 25-34 compared to other age groups. And differences in the epidemiological characteristics of some specific defects from previous studies. Future studies should examine mechanisms. Our findings contributed to clinical counseling and advancing research on the risk factors for birth defects.

A practical method for prenatal diagnosis of anal atresia by second trimester ultrasound screening - A retrospective study

OBJECTIVES

The study aimed to demonstrate the performance of anal atresia ultrasound screening in the second trimester and to describe associated experiences in a primary care fetal medicine clinic.

MATERIALS AND METHODS

We retrospectively analyzed the medical records of fetuses who underwent a second-trimester screening at the Taiji clinic between November 2019 and May 2022. Fisher's exact test was conducted to investigate potential risk factors.

RESULTS

There were 28 459 fetuses screened in our clinic during the study period; eventually, 6 cases were diagnosed with anal atresia after birth. The incidence of anal atresia in our sample was 2.11 in 10 000. Based on our findings, potential risk factors significantly associated with anal atresia included: multiple pregnancies (p-value = 0.0185) and in-vitro fertilization (p-value = 0.038). Half of the anal atresia cases were associated with abnormalities affecting other organ systems, most frequently the genitourinary system (66.7%) and cardiovascular system (66.7%), especially persistent left superior vena cava (2 cases).

CONCLUSION

Anal atresia is a malformation that requires extensive care; the clinical management after the prenatal discovery of its signs should include testing for chromosomal abnormalities and close monitoring of the amniotic fluid volume. Therefore, prenatal ultrasound screening for anal atresia in the second trimester is critical, particularly in the cases of multiple and IVF pregnancies, and multiple abnormalities. The fetuses with ultrasound signs of anal atresia should be followed at a later gestational period and referred to a specialized institution for postnatal management planning and parental counseling.

A Study of the Clinical Profile and Management of Children With Anorectal Malformations

Introduction The diagnosis of anorectal malformations (ARMs) antenatally is rare, and most of these cases are diagnosed in the neonatal period. The defects range from easily treated minor anomalies with good prognosis to those that are difficult and complex. The associated anomalies in these malformations are important determinants for the prognosis and outcome of these cases. Material and methods  The present study was carried out in the department of pediatric surgery in a tertiary care institute. Patients presenting with ARMs in the neonatal period, those reported for definitive surgery, and patients for colostomy closure surgery were included. Patients who died before surgical treatment were excluded from the study. Convenience sampling of 100 patients who met the inclusion criteria was performed until the sample size was reached. Results Out of 63 cases of high variety, 84.12% were males and 15.87% were females. Out of 37 patients of low variety, 43.24% were males and 56.75% were females. The anomalies of the urogenital system were present in 22 (34.92%) out of 63 cases of high ARMs and 10 (27.02%) out of 37 cases of low ARMs. In the male patients, anocutaneous fistula was in 16 (23.18%) of cases. Out of 31 females in the present study, anorectal agenesis with anovestibular fistula was seen in 19 (61.29%) cases. In the early complications, significant bleeding and urethral injury were seen in one (2.63%) patient each. However, among the late complications, anal stenosis, mucosal prolapse, and wound infection were seen in seven (18.42%), five (13.15%), and four (10.52%) patients, respectively. Conclusion  A holistic approach to the management of ARMs is needed with a long-term goal of achieving urinary and fecal continence with good quality of life. The outcome of surgery is dependent on the specific type of malformation, but the results are better when intervention is done early.

Outcome after vaginal delivery of women with a previous medical history of surgically corrected anorectal malformations: a systematic review

OBJECTIVE

Discussion remains on how to advise women with a past medical history of surgically corrected anorectal malformations (ARMs) regarding vaginal delivery. The aim of this review is to evaluate and review the reported obstetrical complications and outcomes after vaginal delivery for these women.

DATA SOURCES

A systematic search was performed from inception up to 25 July 2022 in PubMed, Embase.com and Clarivate Analytics/Web of Science Core Collection, with backward citation tracking.

STUDY ELIGIBILITY CRITERIA/APPRAISAL

All articles reported on the outcomes of interest in women with a past medical history of surgically corrected anorectal malformation and had a vaginal delivery were included with the exception of editorial comments or invitational commentaries. Screening, data extraction and risk of bias assessment was done by two authors independently with a third and fourth reviewer in case of disagreement. Tool for Quality assessment depended on the type of article. As low quality evidence was expected no meta-analysis was performed.

RESULTS

Only five of the 2377 articles screened were eligible for inclusion with a total of 13 attempted vaginal deliveries in eight women. In three patients complications were reported: failed vaginal delivery requiring urgent cesarean section in two patients, and vaginal tearing in one patient.

CONCLUSION

High quality evidence regarding outcomes and complications after vaginal delivery in women with a history of surgically corrected anorectal malformation is lacking. Therefore, based upon this systematic review no formal recommendation can be formulated regarding its safety. Future studies are essential to address this problem.

TRIAL REGISTRATION

CRD42020201390. Date: 28-07-2020s.

Impact of "Lateralizing" the Sigmoid Colostomy on Port Ergonomics in Laparoscopic Anorectoplasty for High Anorectal Malformations

INTRODUCTION

 The high-type anorectal malformations (ARM) are conventionally managed by an initial left iliac fossa sigmoid colostomy, followed by laparoscopic anorectoplasty (LARP). Such a stoma occupies left half of the infraumbilical region and hinders the LARP ergonomics, leading to the surgeon's discomfort. We studied the outcome and impact of "lateralizing" (shifting laterally in the abdominal wall) the colostomy on port ergonomics.

MATERIALS AND METHODS

 This prospective study was conducted in the pediatric surgery unit of a medical college in central India between March 2014 and June 2017 in two parts. In the first part of the study, neonates with high ARM were block randomized in two groups: conventional colostomy (CC) in left iliac fossa and lateral colostomy (LC, laterally placed abdominal colostomy). Outcomes of colostomy were compared among these two groups. In the second part of the study, 40 consecutive infants from both types of colostomy groups underwent ergonomic comparison and assessment of the surgeon's discomfort during LARP (CC-LARP and LC-LARP). Standard statistical tests were used for comparison.

RESULTS

 In the first part of the study, 203 ARM cases were included in this study; 100 underwent CC and 103 underwent LC. Colostomy prolapse, excoriation, reversed stoma, and short distal limb were significantly higher in the CC group. In the second part of the study, the LC-LARP group showed many significant advantages over the CC-LARP group, including less peri-stomal adhesions, better vision, shorter operative time, and better ergonomics (better manipulation, elevation, and azimuth angles). The LC-LARP also significantly reduced the surgeon's discomfort.

CONCLUSION

 Lateralization of high-sigmoid colostomy should be preferred over left iliac fossa sigmoid colostomy for ARM, as it improves the port ergonomics and reduces the surgeon's discomfort for second stage LARP.

Risk factors of vesicoureteral reflux and urinary tract infections in children with imperforate anus: A population-based case-control study in Taiwan

Imperforate anus (IA) is associated with several urological anomalies, including vesicoureteral reflux (VUR), a major contributor to high morbidity in patients with anorectal malformations. This retrospective study was performed to elucidate the risk factors of vesicoureteral reflux (VUR) and UTI in children with IA.We used the National Health Insurance Research Database (NHIRD) to estimate the frequency of congenital anomalies of the kidney and urinary tract (CAKUT) in children with IA. We also investigated the frequencies of VUR, UTI, and CAKUT in children with IA along with the risk factors of VUR.We enrolled 613 children between 2000 and 2008 (367 males and 246 females; 489 low-position IA and 124 high-position IA). High-position IA was associated with a significantly increased risk of VUR compared with low-position IA (OR: 2.68, 95% CI: 1.61, 4.45). In addition, children with IA along with CAKUT, hydronephrosis, or UTI had a higher risk of VUR (OR: 8.57, 95% CI: 3.75, 19.6; OR: 7.65, 95% CI: 4.48, 13.1; and OR: 31.8, 95% CI: 11.5, 88.3, respectively). UTI, as well as chromosomal anomalies, were more frequent in children with high-position IA.Patients with a high-position IA had a greater risk of VUR, particularly those with CAKUT, hydronephrosis, or UTI. Such patients must periodically undergo urinalysis to screen for UTI and early voiding cystourethrogram to rule out VUR and prevent consequent renal damage. Chromosomal analysis is suggested to rule out Down syndrome.

Pelvic Floor Muscles Contribution in Surgical Outcome of Children with High-type Anorectal Malformations

As a consequence of high-type anorectal malformations (ARMs) pathogenesis, the pelvic floor muscles remain severely underdeveloped or hypoplastic, the rectal pouch is located at the level or above the puborectalis sling, and the bowel terminates outside the sphincter muscle complex support. For children with high-type ARMs the ultimate objective of therapy is mainly to grow up having bowel continence function that is compatible with a good quality of life, and the final prognosis depends significantly on the grade of development of pelvic floor muscles and the successful entering of the anorectum fully within the support of the external anal sphincter due to intraoperative conservation of the puborectalis sling. Pelvic magnetic resonance imaging (MRI) has recently become the preferred imaging study for prediction of functional outcomes, since it can define the anatomy and evaluate the development of the sphincteric muscles before and after surgical correction. Based on recent literature and our clinical experience, we will discuss the relevance of pelvic floor muscles MRI to the clinical outcome of children with high type ARMs.

Genital anomalies in newborns

Examination of genitalia should be an essential part of newborn assessment. Early detection of congenital disorders is essential to begin appropriate medical or surgical therapy and to prevent complications that could profoundly affect a child's life. The present review aims to describe the main genital anomalies in infants and provide images in order to help the physician in current clinical practice.

Neonatal Renal Failure in the Setting of Anorectal Malformation: A Case Report and Literature Review

Anorectal malformations (ARMs) can occur in isolation or in association with other anomalies, most commonly those of the genitourinary systems. Morbidity and mortality are highest among patients who develop end-stage renal disease (ESRD) either from severe congenital anomalies (dysplastic kidneys) or from repeated infections in those who have vesicoureteral reflux or persistent recto-urinary fistulas. We describe our management strategy for a patient born with an ARM and bilateral dysplastic kidneys to highlight the nuances and complex decision-making considerations required in taking care of this complex patient population. Our patient is a male twin born at 32 weeks' gestational age who was found to have bilateral dysplastic kidneys on prenatal ultrasound. On initial examination, an imperforate anus was identified along with a severe urethral stricture. Full workup also revealed sacral dysgenesis and confirmation of the dysplastic kidneys. On day of life 3, a laparoscopic diverting sigmoid colostomy was performed; urologic evaluation confirmed the severe urethral stricture, which required dilation to place an 8F council tip catheter. Due to his small size, peritoneal dialysis could not be initiated until five weeks of age. As full volumes could not be reached with peritoneal dialysis, he was soon transitioned to continuous renal replacement therapy. At five months of age, a laparoscopic-assisted posterior sagittal anorectoplasty (PSARP) was performed. As his urethral stricture had worsened, a suprapubic catheter had been placed for bladder decompression. Reversal of his colostomy was performed 15 days after PSARP. Unfortunately, the patient required three further surgical interventions due to abdominal wall and inguinal hernias contributing to filling and emptying dysfunction when utilizing peritoneal dialysis. He is currently 16 months of age and remains inpatient due to intermittent hemodialysis requirements along with autocycling of his peritoneal dialysis. He is working on developmental milestones, can pull to a stand, and is currently being evaluated for kidney transplantation. The development of ESRD in a neonate or infant with an ARM is rare and can be due to congenital dysplasia or agenesis of bilateral kidneys. While peritoneal dialysis is the preferred approach, catheter dysfunction can result from intra-abdominal adhesions or inadequate fluid removal from inguinal or abdominal wall hernias that form in the setting of increased intra-abdominal pressure required for peritoneal dialysis. Close collaboration is required between pediatric surgeons, nephrologists, and urologists to facilitate colonic and urologic reconstruction and manage catheter-related complications.

Delayed presentation of anorectal malformations in a tertiary care hospital in India

AIM

To study delayed presentation of ARMs, management and its effect on surgical and functional complications.

METHODS

It is a retrospective study from March 2015 to March 2020. All the patients satisfying the criteria of delayed ARMs, i.e., presenting 7 days after birth were included. Information regarding type of ARM, mode of presentation, time of presentation, associated anomalies, management strategy, postoperative complications and functional outcome was noted. Minimum follow-up period was 6 months.

RESULTS

Out of 102 patients with ARM, 44 patients presented late. Among the 44 patients, 9 were males and 35 were females. Associated comorbidities observed are low birth weight (n = 9) and preterm (n = 13). Associated anomalies observed were cardiac (n = 18), renal (n = 8), other gastrointestinal (n = 5) and skeletal (n = 1). (1) Male: rectourethral fistula-2 (staged repair), anal stenosis-3 (anoplasty) and anocutaneous fistula-4 (anoplasty). (2) Female: vestibular fistula: 15 (6 primary definitive surgery + 9 staged repair), ectopic anus: 3 (staged repair), anal stenosis: 2 (anoplasty), urogenital sinus: 4 (staged repair), H-type ARM: 8 (staged repair) and persistent cloaca: 3 (staged repair). Primary repair was done in 15 patients (34%), and staged repair was done in 29 patients (65.9%). Anoplasty was done in 9 patients, ASARP (modified tsuchida's procedure) in 8 patients and PSARP in 27 patients. Postoperative complications observed were constipation (n = 21, 47.7%), fecal incontinence (n = 12, 27.27%) with perianal excoriation in 2 patients, anal stenosis (n = 3, 6.8%) and rectal mucosal prolapse (n = 2, 4.5%) CONCLUSION: Delayed presentation of ARMs is not uncommon and is more common in females. Management is almost similar to those who present early. Those who present with chronic constipation and megarectum require staged repair. Complications were more frequent with delayed presentation. Hence, every newborn should have careful examination of perineum and screened for ARM to avoid possible morbidity and mortality.

[Morphological criteria for surgical treatment of anorectal malformations in children]

OBJECTIVE

To improve treatment outcomes in patients with anorectal malformations via research of morphological criteria and differentiated approach to surgical correction.

MATERIAL AND METHODS

There were 37 children with various types of anorectal malformations for the period 2000-2019. We analyzed morphological features of atretic rectum wall, fistula, anastomosis with adjacent organs and skin of the perineum.

RESULTS

Morphological research of anorectal malformations made it possible to differentiate treatment strategy and explain the causes of unsatisfactory results after perineal and abdominal-perineal proctoplasty. Incidence and severity of complications, as well as early disability were reduced that significantly improved postoperative quality of life.

CONCLUSION

According to the morphological criteria, deeper mobilization of atretic rectum within at least 2.5-3 cm of the rectal «cone» with intact muscular wall is necessary. This approach was valuable to ensure adequate closure function of the rectum, prevent anal incontinence and restore normal appearance of the perineum. These achievements contributed to decrease in the incidence of admissions, redo surgeries and improvement of social adaptation in children.

Accompanied anomalies in anal atresia or tracheo-esophageal fistula: Comparison with or without VACTERL association

PURPOSE

We evaluated the various accompanied malformations in patients with anal atresia or tracheoesophageal fistula (TEF). Furthermore, we determined the prevalence of VACTERL association and compared the clinical findings with those of patients without VACTERL association.

METHODS

We enrolled the patients with anal atresia or TEF with/without esophageal atresia. We collected the patient data pertaining to accompanied vertebral, cardiovascular, renal or limb anomalies, single umbilical artery, maternal diabetes mellitus or drug history, and gene research.

RESULTS

A total 155 patients (65 boys and 90 girls) were enrolled with 147 cases of anal atresia, 3 cases of TEF, and 5 cases of anal atresia with TEF. The prevalence of accompanied anomalies was 67.1% in cardiovascular, 27.1% in renal, 9.7% in vertebral, 2.6% in limb anomalies, and 3.9% in single umbilical artery. Thirty-six (23.2%) patients were diagnosed with VACTERL association. The patients with VACTERL association had a significantly higher number of male patients (58.3 vs. 37.0%, p = .033) and single umbilical artery (11.1 vs. 1.7%, p = .026), and had a significantly lower birth weight (2.8 vs. 3.1 kg, p = .033) than the patients without VACTERL association. Genetic studies were performed in 111 patients, and 8 (7.2%) had chromosomal abnormalities-3 in VACTERL and 5 in no VACTERL group.

CONCLUSION

We recommend a careful evaluation for VACTERL association in patients with anal atresia or TEF. It is particularly important to screen for a single umbilical artery for features of VACTERL association as well as for other congenital anomalies.

Analysis of Top ten-Cited Articles Published in the Journal of Indian Association of Pediatric Surgeons Over a 10-Year Period

Aim:

The objective was to identify, analyze, and categorize the characteristics (the type of article, country of origin, institution, authorship, topic, and the number of citations) of the articles published in the Journal of Indian Association of Pediatric Surgeons (JIAPS) from 2008 to 2017, with particular focus on the top ten-cited articles.

Materials and Methods:

The above characteristics of the individual articles were tabulated in the Microsoft Excel^® sheet. The number of citations of an article was obtained from three databases (CrosssRef, MEDLINE, and Google Scholar). A final tally was obtained after removing common entries in the databases.

Results:

The total number of articles published was 613. There were 255 case reports, 209 original articles and review articles, and 149 brief communications. The top five countries of origin of the articles were India, United Kingdom (UK), Turkey, Iran, and Saudi Arabia, with 526, 14, 9, 7, and 6 articles, respectively. The institution, authorship, and topics of the top ten-cited articles were noted.

Conclusion:

Case reports are the most common type of articles published in JIAPS. Most of the articles originated from India, followed by the UK and middle-east countries. This analysis may provide insights to the editorial board and the members of IAPS about the trend of research and publications among the pediatric surgeons of India.

Risk factors for anorectal and associated malformations in German children: A 10-year analysis

BACKGROUND

Incidences of anorectal malformations (ARM) occur in 1 of 2000-5000 live births and up to 64% have associated malformations (ARMa). The aim of the study was to evaluate possible prenatal risk factors for ARM in a tertiary hospital.

METHODS

A case-control design was used to compare risk factors in ARM (n = 44) to a control group (CG; n = 26). We used modified prenatal questionnaires, analyzed mothers' prenatal records and participants completed a structured interview. Endpoints were medical history, drug consumption, occupational risk factors, and time point of diagnosis, associated malformations and sensitivity of radiological imaging.

RESULTS

Our results showed that ARM couples had a significantly higher age difference (p = 0.028) compared to CG. ARM mothers had more abnormalities during pregnancy (p = 0.002), more positive vaginal smears of group B streptococci (p = 0.024), urogenital infections (p = 0.005), gestosis (p = 0.03), emesis (p = 0.025) and higher numbers of chronic diseases (p = 0.018). ARM mothers took less medication during pregnancy (p = 0.013) than CG mothers including folic acid (p = 0.041); their intake of iodine tablets was significantly higher (p = 0.035) and they continued smoking for longer (p = 0.036) than CG mothers, and they had more stillbirths (p = 0.035). In using illegal drug and alcohol use, the groups did not show significant differences. ARMa was present in 68.1% (n = 30), of which 45.5% were of urogenital origin (n = 20). ARM diagnosis was made on the first day of life in 72.7% (n = 32), while diagnosis was delayed in 12 patients (27.3%).

CONCLUSION

A combination of different risk factors seem to be associated with the development of ARM, which takes place at an early stage (<7th week) of pregnancy. Therefore, risk factors influencing fetal development must be critically considered. We advocate an interdisciplinary assessment in unclear clinical findings on first day of life to optimize the therapy and positively influence the outcome.

Magnetic Resonance Imaging of the Anal Region: Clinical Applications

Over the past years, magnetic resonance imaging (MRI) has become a cornerstone in evaluating anal canal and adjacent tissues due to its safeness, the three-dimensional and comprehensive approach, and the high soft-tissue resolution. Several diseases arising in the anal canal can be assessed through MRI performance, including congenital conditions, benign pathologies, and malignancies. Good knowledge of the normal anatomy and MRI technical protocols is, therefore, mandatory for appropriate anal pathology evaluation. Radiologists and clinicians should be familiar with the different clinical scenarios and the anatomy of the structures involved. This pictorial review presents an overview of the diseases affecting the anal canal and the surrounding structures evaluated with dedicated MRI protocol.

Anatomic factors predict urinary continence in patient with anorectal malformation

It has been described that patients with more complex anorectal malformations (ARM), lower sacral ratios and spinal anomalies have poorer rates of fecal and urinary continence. While the ARM subtype has been shown to be an independent predictor of fecal continence, it is not well understood how each of these anatomic factors impact urinary continence. The purpose of this study was to identify anatomic factors associated with urinary continence in children born with ARM. We performed a retrospective review of a large prospectively collected database of children with ARM. Inclusion criteria included diagnosis of ARM, age >4 years, available lateral sacral ratio measurement and presence of spinal MRI. Any child with incomplete or absent continence data was excluded. Continence was defined as voiding per urethra volitionally, dry between voids and ≤1 urinary accident per week. Bivariable tests of association and log-binomial regression models were used to examine association between anatomic factors and urinary continence. A total of 434 patients were included in the study. 57.8% (n = 251) were male. Median age was 8.4 years (IQR 6.0-12.3). With regards to severity of ARM, 20.3% (n = 88) were complex, 23.3% (n = 101) were moderate and 56.5% (n = 245) were simple. Lateral sacral ratio included 11.1% (n = 48) that were <0.4, 36.2% (n = 157) 0.4-0.7 and 52.8% (n = 229) > 0.7. Spine status was found to be myelomeningocele in 4.4% (n = 19), low conus or tethered cord in 34.8% (n = 151) and normal or fatty filum in 60.8% (n = 264). Overall 62.2% were continent. ARM severity, lateral sacral ratio and spine status were each independent predictors of urinary continence on univariate and multivariable analysis. We conclude that in children born with ARM, the severity of ARM, lateral sacral ratio and spine status each independently predict urinary continence. These results allow us to better understand these complex patients and their ability to develop urinary continence. This is crucial in enabling proper patient and family counseling and thus, setting appropriate expectations.

Transfistula anorectoplasty on adult female anorectal malformation: A rare case report

INTRODUCTION

Female anorectal malformation (ARM) is correctable congenital defects. Delayed presentation of patients with anorectal malformation is uncommon. However, presentation beyond teenage years is not commonplace. We describe a case of ARM with rectovestibular fistula and anal atresia.

PRESENTATION OF CASE

A 31 years old woman with chief complaint of small vaginal introitus. Gynecology examination showed urethra, labia majora, labia minora, and small vaginal introitus. Vaginal length was 6 cm. There was no anal canal. The patient underwent transfistula anorectoplasty and modified Fenton procedure.

DISCUSSION

The important step of transfistula anorectoplasty (TFARP) procedure is the placement of neoanus in the center of external spinchter to provide continence. The absence of skin incision in anterior and posterior to the neoanus provide good cosmetic result. Compared to PSARP procedure, TFARP procedure has advantage which is the absence of separation of the skin in the midline buttock, the levator muscle, and the external spinchter complex. This lead to optimal fecal continence. In our experience, TFARP is a safe and effective procedure. Daily vaginal dilation in postoperative period is unnecessary. This technique also give good cosmetic result with optimal fecal continence and sexual function.

CONCLUSION

Transfistula anorectoplasty procedure for ARM give give good cosmetic result and optimal fecal continence and sexual function.

Characteristics of Anorectal Malformations in Children at the United States-Mexico Border: A 3-Year Study

BACKGROUND

Anorectal malformations (ARMs) are a group of congenital malformations affecting the lower gastrointestinal, urogenital, and/or gynecological systems. They occur in approximately 1 in 5000 live births, with a slight male predominance. ARMs can appear in isolation or in association with other anomalies. The literature contains little information about the characteristics of ARMs in United States Hispanic populations.

METHODS

An institutional review board-approved chart review was conducted in all patients with ARMs seen at a single institution in El Paso, Texas, from January 2012 to December 2015. Data regarding demographics, types of ARMs, associated syndromes, and long-term complications were recorded using the Krickenbeck classification system.

RESULTS

Of the 37 patients included in the study, 20 were boys and 17 were girls. The most common ARMs were rectoperineal fistula (46%), rectourethral fistula, and cloacal malformation. Constipation was the most common long-term complication, especially in patients with recto-perineal fistula.

CONCLUSION

Children in the Borderland community may have a higher percentage of recto-perineal fistula than previously reported. Postoperative complications in Hispanic children with ARM were comparable to those reported in other populations.

Challenges in pediatric urologic practice: a lifelong view

The role of the pediatric urologic surgeon does not end with initial reconstructive surgery. Many of the congenital anomalies encountered require multiple staged operations while others may not involve further surgery but require a life-long follow-up and often revisions. Management of most of these disorders must extend into and through adolescence before transitioning these patients to adult colleagues. The primary goal of management of all congenital uropathies is protection and/or reversal of renal insult. For posterior urethral valves, in particular, avoidance of end-stage renal failure may not be possible in severe cases due to the congenital nephropathy but usually can be prolonged. Likewise, prevention or minimization of urinary tract infections is important for overall health and eventual renal function. Attainment of urinary continence is an important goal for most with a proven positive impact on quality of life; however, measures to achieve that goal can require significant efforts for those with neuropathic bladder dysfunction, obstructive uropathies, and bladder exstrophy. A particular challenge is maximizing future self-esteem, sexual function, and reproductive potential for those with genital anomalies such as hypospadias, the bladder exstrophy epispadias complex, prune belly syndrome, and Mullerian anomalies. Few endeavors are rewarding as working with children and their families throughout childhood and adolescence to help them attain these goals, and modern advances have enhanced our ability to get them to adulthood in better physical and mental health than ever before.

The early outcome of primary anterior sagittal approach for low anorectal malformations in female patients

Objective:

To document our experience of the primary anterior sagittal anorectoplasty (ASARP) in female patients with lower and wide fistula in term of the early post operative outcome.

Methods:

A retrospective descriptive study was conducted in one surgical unit of the National Institute of Child Health Karachi, from January 2010 to April 2018. The study included female patients with diagnosis of imperforate anus with wide Vestibular or Perineal fistula with minimal or no straining during defecation and no excoriation of perineum. All patients underwent primaryASARP. Data regarding the age of the patients, site of fistula, the difficulties in dissection, post operative complications, stoma and re-do ASARP needed, were documented. Wound assessment was done during hospital stay, at two weeks and then at three months after surgery. Outcome was documented in terms of complications of surgery and cosmetic appearance of perineum. Data was analyzed on SPSS version 20.

Results:

A total of 70 patients underwent primary surgery, 48(68.57%) females had perineal fistula while 22(31.42%) had vestibular fistula. Age ranges between three months to 276 months with median of 6±39.73 months. No major injury to the rectal or vaginal wall occurred during surgical procedure. In early post-operative period, 12(17.14%) patients had wound infection with or without various extent of disruption. A total of seven (10.11%) patients underwent stoma formation, six (8.57%) patients because of wound disruption with in a week of primary surgery and in one patient due to severe anal stenosis and retraction of anal segment within three month follow up. Median hospital stay was 5±1.52 days. In 38(54.28%) paients complete wound healing occurred with no per or post operative complications. In 25(35.71%) patients, minor complications were noted and treated accordingly and results were labelled satisfactory with acceptable perineal appearance.

Conclusion:

The single stage procedure can be a good choice for both vestibular and perineal fisula. In majority of cases wound heals completely with minimal or no scaring and give good cosmetic results.

Risk factors associated with anorectal malformations development. A case-control study

Objectives:

To determine the risk factors for the development of anorectal malformations (ARM).

Methods:

This case-control study was conducted in the Maternity and Children Hospital (MCH), Al Madinah Al Munnawarah, Saudi Arabia. The sample was taken from the ARM cases admitted at MCH between January 2013 and December 2017. The controls were selected from well-baby clinics in primary health care centers. Parents of the cases and the controls were interviewed based on a questionnaire. Descriptive, univariate, and multivariate logistic regression were used in the analysis.

Results:

The study included 48 cases and 96 controls with 31 (64.6%) cases of isolated ARM and 17 (35.4%) cases of associated ARM. Among the ARM cases, 27 (56.3%) were males and 21 (43.8%) were females. In multivariate analysis, we found consanguinity to be associated with an increased risk of developing ARM with odds ratio (OR): 2.43, 95% CI: 1.12-5, and p=0.025, in addition to maternal obesity, with OR: 4.36, 95% CI: 1.2-15.8, and p=0.025.

Conclusion:

Consanguinity and maternal obesity (body mass index >30) were found to be risk factors for ARM development.

Missing anus: Do not miss it

Anorectal malformations (ARMs) are commonly encountered in clinical practice, with an incidence of about 1 in 5000 live births. They are diagnosed in early neonatal period when on routine neonatal examination at birth, anal opening is found to be absent or abnormally located. We present a neonate whose ARM was initially missed due to a cursory examination of perineal area. The lesson learnt would be of great value for the clinical examination of a newly born baby.

Bowel Imaging in Children: Part 1

The bowel is a challenging abdominal organ to image. The main reason is the variable location, convoluted morphology and motility. A variety of bowel disorders such as congenital, developmental, inflammatory, infectious and neoplastic lesions can affect children and most of them are either unique to this age group or have a distinct clinico-radiological appearance compared to adults. Imaging plays a very important role in characterizing these lesions and further guiding the management. This is the first part of the series on imaging of bowel disorders in children. This article will cover the imaging modalities used for the evaluation of bowel and the imaging features of congenital /developmental disorders.

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.

Patterns and treatment outcomes of anorectal malformations in Mbarara Regional Referral Hospital, Uganda

BACKGROUND/PURPOSE

Anorectal malformation (ARM) is a common condition. Owing to scarcity of pediatric surgery services in Uganda, however, relatively little is known about this condition.

METHODS

This was a retrospective review of medical records of all patients admitted to Mbarara Regional Referral Hospital (MRRH) from January 2014 to May 2016. MRRH serves 3-8 million people in southwest Uganda. We also enrolled patients prospectively from June 2016 to December 2016.

RESULTS

78 patients were enrolled in the study. 63.38% had delayed diagnosis (presenting >48 h after birth), and most of these were self-referrals from home. The most common malformation was a vestibular fistula. Associated congenital anomalies were seen in 20% of patients, and this was associated with increased mortality. These anomalies included limb, eye, ear and genitourinary anomalies as well as ventricular septal defects, patent ductus arteriosus, spina bifida and tracheoesophageal fistula. Posterior sagittal anorectoplasty (PSARP) was the definitive surgery used. It was performed in 58.97% of the patients. Median age of patients who underwent PSARP was 11 months. 73.91% of PSARP patients had their colostomies closed and 62.5% of these who were ≥3 years old had good continence outcomes. Overall mortality rate was 8.97%.

CONCLUSION

The majority of patients are diagnosed late. Vestibular fistula is the overall most common type of ARM. In males, however, rectourethral fistula is the most common type. Definitive surgery at MRRH is performed late. Continence outcomes are good and comparable to other countries with more resources.

LEVEL OF EVIDENCE

III.

Is Pouch Specific to Colon and Not Ileum?

BACKGROUND

Congenital Pouch Colon (CPC) is an anorectal anomaly with an incidence of 3.5:1 in males and females, respectively. We have earlier reported CPC to be quite prevalent in north Indian tertiary care centers.

OBJECTIVE

In this article, we deliberate on the possible causes associated with CPC bringing the manifestation of the disease. In addition, we throw insights on the effective role of this congenital anomaly in Colon and provide systems genomic evaluation by comparing our recent analysis to that of Colon and Ileum based on Next-Generation Sequencing (NGS) studies.

CONCLUSION

In this commentary article, we argue that a host of epigenetic factors could be the reason why the disease is manifested in colon alone. We further hypothesize on the few unmet challenges linking epigenetics to understand the genetic variants.

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.

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.

Anorectal malformations: Role of MRI in preoperative evaluation

PURPOSE

To evaluate the spectrum of magnetic resonance imaging (MRI) findings in pediatric patients with anorectal malformation (ARM) and compare the accuracy of MRI and distal cologram (DC) findings using surgery as reference standard.

MATERIALS AND METHODS

Thirty pediatric patients of age less than 14 years (19 boys and 11 girls) with ARM underwent preoperative MRI. MRI images were evaluated for the level of rectal pouch in relation to the pelvic floor, fistula, and development of sphincter muscle complex (SMC). Associated spinal and other anomalies in lumbar region and pelvis were also evaluated. DC was done in 26 patients who underwent colostomy. Ultrasound of abdomen and pelvis was also done for associated anomalies.

RESULTS

Overall accuracy of MRI and DC to detect the exact level of rectal pouch including cloacal malformation was 93.33% and 76.9% respectively. MRI and DC could correctly identify presence or absence of fistula in 76.6% and 76.9% cases respectively. MRI and DC correctly identified the anatomy of fistula in 76% and 65% cases respectively. On MRI, correlation of development of levator ani and puborectalis with the level of rectal pouch as found on surgery was significant (P = 0.008; 0.024 respectively). Subjective assessment of sphincter muscle development on MRI correlated well with the surgical assessment [P = 0.019 and 0.016 for puborectalis and external anal sphincter (EAS) respectively]. Lumbosacral spine anomalies were present in 33.3% of patients and were most common in high type of ARM. Vesicoureteric reflux and renal agenesis were the most common renal and urinary tract anomalies and were present in 40% of cases.

CONCLUSION

MRI allows reliable preoperative evaluation of ARM and should be considered as a complementary imaging modality for preoperative imaging in ARM.

Unusual case of coronal complete bladder duplication associated with rectoprostatic fistula to duplicated prostatic urethra

Anorectal malformations are a common congenital anomaly, while bladder duplication is rare. Bladder duplications are classified as complete or incomplete and sagittal or coronal. We present a rare case of coronal complete bladder duplication with rectoprostatic fistula to the blind ending prostatic urethra of the duplicated bladder.

Anorectal Malformations: Histomorphological and Immunohistochemical Evaluation of Neuronal Dysfunction

Objective :

The patients with anorectal malformations (ARM) have been identified with specific and non-specific pathological changes. The present study was conducted with the aim to study histomorphological changes and various immunohistochemical (IHC) markers (calretinin, S-100, CD117) in intestinal wall specimens to assess neuronal dysfunction in ARM patients.

Material and methods :

Thirty children having ARM were included in our study. In all the cases, a representative biopsy was received. The tissue sections were processed and wax blocks were prepared. Various histopathological changes were examined on routine H&E. Representative sections were further subjected to IHC staining for ganglion cells (calretinin), interstitial cells of Cajal (CD117) and nerve bundles (S-100 protein). Descriptive variables were analyzed to assess neuronal dysfunction in cases of ARM. Chi-square was used to compare the categorical values. P-value <0.05 was accepted as statistically significant.

Results :

Biopsies were studied for histological changes using H&E stain. The most frequently observed histological finding in mucosa was inflammation and congestion in 87% and 67% of cases respectively. Disrupted muscularis mucosa was observed in 60%, eroded mucosa in 57%, and hemorrhage in 40% of cases. Submucosal inflammation and congestion were most common finding observed in submucosa in 87% and 80% cases respectively. CD117 was used to demonstrate altered density and distribution of interstitial cells of Cajal (ICC) in cases of ARM. Majority of them belong to grade 2+ category (n=17, 57%) followed by grade 1+ (n=8, 17%) for ICC cells. Altered density and distribution of ICC was observed in ARM which was statistically significant (p=0.02).

Conclusion :

The malformed segments in ARM show various specific and non-specific histomorphological changes. Examination of H&E sections along with IHC stains evaluation can minimize need for repeated biopsies and unnecessary radical treatment. CD117 immunohistochemistry is reliable adjunctive test in evaluation of ICC in motility disorders of bowel. Calretinin is good marker for identification of ganglion cells. In ARM, density and distribution of ICCs is significantly altered which can explain postoperative dysmotility.

Transient Distention of Right Posterior Located Sigma, a New Sonographic Sign for the Prenatal Diagnosis of Anal Atresia

We describe a new sonographic sign for the detection of anal atresia in the early midtrimester on transvaginal sonography. In six cases of fetal anal atresia, the finding of a transient, distended, and right-sided sigmoid colon was observed at 13-16 weeks' gestation. Three cases have undergone pregnancy termination due to multiple anomalies. In the other three, the colonic distension resolved by 19 weeks' gestation. In two of these, the finding was isolated, and no other anomalies were detected. In all six cases, anal atresia or cloaca was confirmed on postabortal autopsy or after delivery. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:160-162, 2017.

Laparoscopically Assisted Anorectal Pull-Through versus Posterior Sagittal Anorectoplasty for High and Intermediate Anorectal Malformations: A Systematic Review and Meta-Analysis

Objective

Anorectal malformations (ARMs) are one of the commonest anomalies in neonates. Both laparoscopically assisted anorectal pull-through (LAARP) and posterior sagittal anorectoplasty (PSARP) can be used for the treatment of ARMs. The aim of this systematic review and meta-analysis is to compare these two approaches in terms of intraoperative and postoperative outcomes.

Methods

MEDLINE, Embase, Web of Science and the Cochrane Library were searched from 2000 to August 2016. Both randomized and non-randomized studies, assessing LAARP and PSARP in pediatric patients with high/intermediate ARMs, were included. The primary outcome measures were operative time, length of hospital stay and total postoperative complications. The second outcome measures were rectal prolapse, anal stenosis, wound infection/dehiscence, anorectal manometry, Kelly's clinical score, and Krickenbeck classification. The quality of the randomized and non-randomized studies was assessed using the Cochrane Collaboration's Risk of Bias tool and Newcastle-Ottawa scale (NOS) respectively. The quality of evidence was assessed by GRADEpro.

Results

From 332 retrieved articles, 1, 1, and 8 of randomized control, prospective and retrospective studies, respectively, met the inclusion criteria. The randomized clinical trial was judged to be of low risk of bias, and the nine cohort studies were of moderate to high quality. 191 and 169 pediatric participants had undergone LAARP and PSARP, respectively. Shorter hospital stays, less wound infection/dehiscence, higher anal canal resting pressure, and a lower incidence of grade 2 or 3 constipation were obtained after LAARP compared with PSARP group values. Besides, the LAARP group had marginally less total postoperative complications. However, the result of operative time was inconclusive; meanwhile, there was no significant difference in rectal prolapse, anal stenosis, anorectal manometry, Kelly's clinical score and Krickenbeck classification.

Conclusion

For pediatric patients with high/intermediate anorectal malformations, LAARP is a better option compared with PSARP. However, the quality of evidence was very low to moderate.