A comparison of laparoscopic-assisted (LAARP) and posterior sagittal (PSARP) anorectoplasty in the outcome of intermediate and high anorectal malformations.

Division of Paediatrics Surgery, Stellenbosch University, Tugersberg, W Cape.
South African journal of surgery. Suid-Afrikaanse tydskrif vir chirurgie (Impact Factor: 0.57). 02/2011; 49(1):39-43.
Source: PubMed

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: Aim and purpose:The aim of this study was to evaluate the outcome of patients who underwent posterior sagittal anorectoplasty (PSARP) for the treatment of low or high anorectal malformation (ARM). Patients and methods: All patients who underwent standard PSARP were included in this study. Patients with mental retardation were excluded from our study. Patients were classified according to the Rintala score into four categories: poor (6–9); fair (9–11); good (12–17); and normal (18–20). We used a questionnaire introduced by Rintala. The type of anomaly was divided into two categories. We used low and high ARM definitions according to the relationship of the terminal colon to the levator muscles of the pelvic floor. The Student t-test, the Pearson χ2-test, one-way analysis of variance, and the Levine test were used for data analysis using SPSS ver. 13.0. Results: Sixty patients aged 3–17 years (13.63±3.27 years) were included. The mean of score in patients with low-type ARM was 14.5±2.6 and that in patients with high-type ARM was 13.19±3.75 (P=0.28). The mean of scores was 13.34±3.5 among male patients and 13.94±2.9 among female patients. There was no statistically significant difference (P=0.46). The score was significantly higher in patients with fistula (n=51, 13.9±3.1) than in patients without fistula (n=9, 11.8±3.3; P=0.03). Excluding two cases with scrotal-type fistula and rectal atresia, there was no significant difference between the two groups (P=0.06). Conclusion: There was no significant difference in the outcome after PSARP between boys and girls. There was no significant difference between low-type and high-type ARM. The mean of score was significantly higher among patients with fistula than among patients without fistula.
    Annals of Pediatric Surgery. 07/2014; 10(3):65-67.
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    ABSTRACT: Purpose The aim of the study is to assess the characteristics and outcome of anorectal malformation (ARM) patients who underwent single-stage repair of perineal fistula without colostomy according to the Krickenbeck classification. Methods From 2002 to 2013, twenty-eight males and four females with perineal fistula who underwent single-stage repair without colostomy in our institute were included in this study. Patients with perineal fistula who underwent staged repair were excluded. Demographics, associated anomalies, and operative complications were recorded. The type of surgical procedures and functional outcome were assessed using the Krickenbeck classification. Results Six patients had associated anomalies, including two patients with renal, two with cardiac, one with vertebral, and one with limb abnormalities. Thirteen patients underwent perineal operation, and fourteen patients underwent anterior sagittal approach in the neonatal period. One patient underwent anterior sagittal approach, and four patients underwent PSARP beyond the neonatal period. One patient had an intra-operative urethral injury and one a vaginal injury. Complications were not associated with the type of surgical procedure (p = 0.345). All perineal wounds healed without infection. By using the Krickenbeck assessment score, all sixteen children older than five years of age had voluntary control. One patient had grade 1 soiling, and no patient had constipation. Conclusions Single-stage operation without colostomy was safe with good outcomes in patients with perineal fistula. The use of Krickenbeck classification allows standardization in assessment on the surgical approach and on functional outcome in ARM patients.
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    ABSTRACT: Despite the advances of laparoscopic surgery in pediatric surgery, its role in anorectoplasty remains controversial. Indeed, some surgeons are reluctant to perform laparoscopic surgery for anorectal malformation. In this review article, current evidence for laparoscopic anorectoplasty is discussed and outcomes of this operation will be highlighted.
    Surgical Practice 02/2014; · 0.17 Impact Factor