A comparison of laparoscopic-assisted (LAARP) and posterior sagittal (PSARP) anorectoplasty in the outcome of intermediate and high anorectal malformations.
ABSTRACT Laparoscopic-assisted ano-rectoplasty (LAARP) has gained popularity since its introduction in 2000. Further evidence is needed to compare its outcome with the gold standard of posterior sagittal ano-rectoplasty (PSARP).
A retrospective review of patients presenting with ano-rectal malformation (ARM) in the period 2000 - 2009. Demographics, associated abnormalities, and operative and post-operative complications were assessed. The functional outcome in children older than 3 years was assessed, applying the Krickenbeck scoring system and, where possible, by interviewing parents. Patients with cloacal abnormalities were excluded. Patients with a LAARP were compared with those managed by PSARP.
Seventy-three patients with ARM were identified during the study period. Male to female ratio was 1.6:1. All 32 low ARMs (perineal and vestibular fistulae) were excluded. Thirty-nine had levator or supra-levator lesions. Twenty males presented with recto-bulbar, 3 with recto-prostatic, and 1 with a recto-vesical fistula; 2 had no fistula; and in 2 the data were insufficient to determine the level. Among the females, 6 had recto-vaginal fistulae, 4 had cloacas and 1 had an ARM without fistula. There were 3 syndromic ARMs (2 Trisomy 21 and 1 Baller-Gerald syndrome). One neonate with a long-gap oesophageal atresia had a successful primary LAARP. Seventy-five per cent of all patients had VACTERL associations. Two early deaths after colostomy formation were related to a cardiac anomaly and an oesophageal atresia. In both groups, mean age at anoplasty was 8 months. Twenty of the intermediate/high lesions were treated with LAARP, and 19 by PSARP. There were slightly more complications in the LAARP group; intra-operative injury to the vas deferens and urethra occurred once each. Post-operatively, 2 port-site hernias and 1 case of pelvic sepsis occurred. A poorly sited colostomy caused difficulty in 2 patients. Two patients were converted to laparatomy: severe adhesions in one and a poorly sited stoma in another. Five patients required redo-anoplasty for mucosal prolapse, anal stenosis, incorrect placement of the anus, retraction of the rectum and an ischaemic rectal stricture. Complications in the PSARP group included 2 wound dehiscences, 1 anal stenosis, 3 mucosal prolapses, 1 recurrent fistula and 2 incorrect anal placements requiring redo surgery. The Krickenbeck questionnaire was used in 70% of PSARPs (mean age 5.9 years) and LAARPs (mean age 5.5 years) for a functional assessment. Both groups showed voluntary bowel movements in 14%. Soiling and overflow incontinence was a significant problem. Grade III constipation was less common in the LAARP (14%) than PSARP (21%) group. Four patients in the LAARP group were reliant on regular rectal washouts compared, with 6 in the PSARP group.
Both LAARP and PSARP can successfully treat ARM but have specific associated problems.
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ABSTRACT: Various management strategies for anorectal malformations (ARM) have been proposed. The aim of this study was to assess the current management in centers of excellence in Europe. An online survey on the pre- and post-operative concepts, surgical techniques, and the management of complications was sent to the representative experts of 28 selected European centers of pediatric surgery with special expertise in the treatment of ARM. The survey was completed by 25 experts from 14 countries. To assess the level of the rectal pouch in newborns 60 % of participants perform a prone cross-table X-ray and 52 % ultrasound. If an ostomy is required, 84 % create divided Peña stomas. Primary repair in the newborn period is performed in females with rectoperineal (92 %), rectovestibular (60 %), and no fistula (32 %), and in males with rectoperineal (92 %), rectourinary (17 %) and no fistula (38 %). For 68 % of surgeons, the PSARP is the preferred surgical approach for "low" malformations. Laparoscopically assisted pull-throughs are routinely performed by 48 % of experts for ARM with bladderneck and 28 % for rectoprostatic fistula. 88 % perform postoperative dilations. The management of ARM in Europe is very heterogeneous. High-quality clinical studies are needed to provide scientific evidence for the optimal treatment strategies.Pediatric Surgery International 04/2015; 31(6). DOI:10.1007/s00383-015-3700-5 · 1.06 Impact Factor
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ABSTRACT: Seventeen years have passed since the first description of the laparoscopic approach for anorectal malformation and approximately 68 articles have been published on the subject. In this review article, we aim to describe the advantages as well as the indications and contraindications of this approach when dealing with each specific type of anorectal malformation, according to what has been described in the literature and to our own experience. The ideal and undisputable indication for laparoscopy remains for cases in which the abdomen needs to be entered to repair the malformation. Only 10 % of male patients with anorectal malformation are born with a recto-bladder neck fistula that requires an abdominal approach, this represents an ideal indication for laparoscopy. In females, only the complex cloacae with a common channel length greater than 3 cm are the ones that require a laparotomy; they represent about 30 % of the cloacae. However, the repair of this type of cloacae also requires sophisticated and technically demanding maneuvers that have never been done laparoscopically. In cases of recto-urethral prostatic fistulas the malformation can be repaired either way: laparoscopically or posterior sagitally. In all other malformations: recto-perineal fistula, recto-urethral bulbar fistula, anorectal malformation without fistula, rectal atresia, recto-vestibular fistula; no justification for laparoscopy could be found; and in some cases, laparoscopy is contraindicated. In the published reports, there is no evidence supporting the idea that laparoscopic repair results in better functional results when compared with non-laparoscopic operation; there is a tendency to omit information relevant to bowel control such as the characteristics of the sacrum and the presence or absence of tethered cord; and most authors do not compare results between comparable malformations.Pediatric Surgery International 03/2015; 31(5). DOI:10.1007/s00383-015-3687-y · 1.06 Impact Factor
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ABSTRACT: Aim Despite the advances of laparoscopic surgery in paediatric surgery, its role in anorectoplasty remains controversial. This review article aims at discussing current evidences regarding this new operative approach. Methods Literature review for laparoscopic anorectoplasty was performed in combination with experience from our centre. Details on operative techniques, surgical complications and postoperative outcomes were highlighted. Results Laparoscopic anorectoplasty (LAR) can be performed safely and effectively in early infantile period with modern small-sized laparoscopic instruments. Postoperative complications have been reported to range from 0.8 to 7.2 per cent. Apart from general surgical complications, fistula and cyst formations at the posterior urethra are two specific complications. Functional outcomes are not inferior to traditional posterior sagittal anorectoplasty (PSARP) with less surgical trauma and better cosmetic result especially in high-type malformations. Similarly, outcomes of LAR are comparable with PSARP under manometric and radiological assessments. Conclusions Based on current evidences, LAR appears to be at least as good as PSARP. In high-type malformations, we recommend that LAR be considered as the operation of choice. However, good laparoscopic skills and proper laparoscopic instruments are essential when performing this operation.Surgical Practice 02/2014; 18(2). DOI:10.1111/1744-1633.12059 · 0.17 Impact Factor