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Eur J Pediatr Surg 2023; 33(06): 463-468
DOI: 10.1055/a-1976-3611
Original Article

Sparing the Perineal Body: A Modification of the Posterior Sagittal Anorectoplasty for Anorectal Malformations with Rectovestibular Fistulae

Andrea Badillo
1   Division of Colorectal and Pelvic Reconstruction, Children's National Medical Center, Washington, District of Columbia, United States
,
Laura Tiusaba
1   Division of Colorectal and Pelvic Reconstruction, Children's National Medical Center, Washington, District of Columbia, United States
,
Shimon Eric Jacobs 
1   Division of Colorectal and Pelvic Reconstruction, Children's National Medical Center, Washington, District of Columbia, United States
,
Tamador Al-Shamaileh
2   Department of General Surgery, Faculty of Medicine, Mutah University, Karak, Jordan
,
Christina Feng
1   Division of Colorectal and Pelvic Reconstruction, Children's National Medical Center, Washington, District of Columbia, United States
,
Teresa Lynn Russell 
1   Division of Colorectal and Pelvic Reconstruction, Children's National Medical Center, Washington, District of Columbia, United States
,
Elizaveta Bokova
1   Division of Colorectal and Pelvic Reconstruction, Children's National Medical Center, Washington, District of Columbia, United States
,
Anthony Sandler
1   Division of Colorectal and Pelvic Reconstruction, Children's National Medical Center, Washington, District of Columbia, United States
,
Marc A. Levitt
1   Division of Colorectal and Pelvic Reconstruction, Children's National Medical Center, Washington, District of Columbia, United States
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Abstract

Background The posterior sagittal anorectoplasty (PSARP) used to repair an anorectal malformation (ARM) with a rectovestibular fistula involves incising the perineal body skin and the sphincter muscles and a posterior sagittal incision to the coccyx. Perineal body dehiscence is the most common and morbid complication post-PSARP which can have a negative impact on future bowel control. With consideration of all the other approaches described to repair this anomaly, we developed a perineal body sparing modification of the standard PSARP technique.

Methods Four patients with ARM with a rectovestibular fistula were repaired with a perineal body sparing modified PSARP at a single institution between 2020 and 2021. The incision used was limited, involving only the length of the anal sphincter, with no incision anterior or posterior to the planned anoplasty. Dissection of the distal rectum and fistula was performed without cutting the perineal body. Once the distal rectum was mobilized off the posterior vaginal wall and out of the vestibule, the perineal body muscles, where the fistula had been, were reinforced and an anoplasty was then performed.

Results Operative time was the same as for a standard PSARP. There were no intraoperative or postoperative complications. No postoperative dilations were performed. All patients healed well with an excellent cosmetic result. All are too young to assess for bowel control.

Conclusion We present a new technique, a modification of the traditional PSARP for rectovestibular fistula, which spares the perineal body. This approach could eliminate the potential complication of perineal body dehiscence.

Keywords

anorectal malformation - posterior sagittal anorectoplasty - rectovestibular


Publication History

Received: 25 May 2022

Accepted: 07 November 2022

Accepted Manuscript online:
10 November 2022

Article published online:
29 March 2023

© 2023. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

Comment to this article:

Response to: Sparing the Perineal Body, A Modification of the Posterior Sagittal Anorectoplasty (PSARP) for Anorectal Malformations with Rectovestibular FistulaeEur J Pediatr Surg 2023; 33(04): 329-329
DOI: 10.1055/s-0043-1770998

Comment to this article:

Sparing the Perineal Body in the Vestibular FistulaEur J Pediatr Surg 2023; 33(04): 328-328
DOI: 10.1055/s-0043-1770997

 

  • References

  • 1 Minneci PC, Kabre RS, Mak GZ. et al; Midwest Pediatric Surgery Consortium. Screening practices and associated anomalies in infants with anorectal malformations: results from the Midwest Pediatric Surgery Consortium. J Pediatr Surg 2018; 53 (06) 1163-1167
    CrossrefPubMedSearch in Google Scholar
  • 2 Minneci PC, Kabre RS, Mak GZ. et al; Midwest Pediatric Surgery Consortium. Can fecal continence be predicted in patients born with anorectal malformations?. J Pediatr Surg 2019; 54 (06) 1159-1163
    CrossrefPubMedSearch in Google Scholar
  • 3 Kuijper CF, Aronson DC. Anterior or posterior sagittal anorectoplasty without colostomy for low-type anorectal malformation: how to get a better outcome?. J Pediatr Surg 2010; 45 (07) 1505-1508
    CrossrefPubMedSearch in Google Scholar
  • 4 van der Steeg HJJ, van Rooij IALM, Iacobelli BD. et al; ARM-Net consortium. The impact of perioperative care on complications and short term outcome in ARM type rectovestibular fistula: an ARM-Net consortium study. J Pediatr Surg 2019; 54 (08) 1595-1600
    CrossrefPubMedSearch in Google Scholar
  • 5 Tofft L, Salö M, Arnbjörnsson E, Stenström P. Wound dehiscence after posterior sagittal anorectoplasty in children with anorectal malformations. BioMed Res Int 2018; 2018: 2930783
    CrossrefPubMedSearch in Google Scholar
  • 6 Lauriti G, Di Renzo D, Lelli Chiesa P, Zani A, Pierro A. One-stage repair of anorectal malformations in females with vestibular fistula: a systematic review and meta-analysis. Pediatr Surg Int 2019; 35 (01) 77-85
    CrossrefPubMedSearch in Google Scholar
  • 7 Wood RJ, Halleran DR, Ahmad H. et al. Assessing the benefit of reoperations in patients who suffer from fecal incontinence after repair of their anorectal malformation. J Pediatr Surg 2020; 55 (10) 2159-2165
    CrossrefPubMedSearch in Google Scholar
  • 8 Vilanova-Sanchez A, Reck CA, McCracken KA. et al. Gynecologic anatomic abnormalities following anorectal malformations repair. J Pediatr Surg 2018; 53 (04) 698-703
    CrossrefPubMedSearch in Google Scholar
  • 9 Ahmad H, Skeritt C, Halleran DR. et al. Are routine postoperative dilations necessary after primary posterior sagittal anorectoplasty? A randomized controlled trial. J Pediatr Surg 2021; 56 (08) 1449-1453
    CrossrefPubMedSearch in Google Scholar
  • 10 deVries PA, Peña A. Posterior sagittal anorectoplasty. J Pediatr Surg 1982; 17 (05) 638-643
    CrossrefPubMedSearch in Google Scholar
  • 11 Peña A, Devries PA. Posterior sagittal anorectoplasty: important technical considerations and new applications. J Pediatr Surg 1982; 17 (06) 796-811
    CrossrefPubMedSearch in Google Scholar
  • 12 Peña A. Preface: advances in anorectal malformations. Semin Pediatr Surg 1997; 6: 165-169
    PubMedSearch in Google Scholar
  • 13 Levitt MA, Peña A. Outcomes from the correction of anorectal malformations. Curr Opin Pediatr 2005; 17 (03) 394-401
    CrossrefPubMedSearch in Google Scholar
  • 14 Levitt MA, Peña A. Anorectal malformations. Orphanet J Rare Dis 2007; 2: 33
    CrossrefPubMedSearch in Google Scholar
  • 15 de Blaauw I, Midrio P, Breech L. et al. Treatment of adults with unrecognized or inadequately repaired anorectal malformations: 17 cases of rectovestibular and rectoperineal fistulas. J Pediatr Adolesc Gynecol 2013; 26 (03) 156-160
    CrossrefPubMedSearch in Google Scholar
  • 16 Geller EJ, Robinson BL, Matthews CA. et al. Perineal body length as a risk factor for ultrasound-diagnosed anal sphincter tear at first delivery. Int Urogynecol J Pelvic Floor Dysfunct 2014; 25 (05) 631-636
    CrossrefPubMedSearch in Google Scholar
  • 17 Signorello LB, Harlow BL, Chekos AK, Repke JT. Postpartum sexual functioning and its relationship to perineal trauma: a retrospective cohort study of primiparous women. Am J Obstet Gynecol 2001; 184 (05) 881-888 , discussion 888–890
    CrossrefPubMedSearch in Google Scholar
  • 18 American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Obstetrics. Practice bulletin no. 165: prevention and management of obstetric lacerations at vaginal delivery. Obstet Gynecol 2016; 128 (01) e1-e15
    CrossrefPubMedSearch in Google Scholar
  • 19 Levitt MA, Kant A, Peña A. The morbidity of constipation in patients with anorectal malformations. J Pediatr Surg 2010; 45 (06) 1228-1233
    CrossrefPubMedSearch in Google Scholar
  • 20 Potts WJ, Riker WL, Deboer A. Imperforate anus with recto-vesical, -urethral-vaginal and -perineal fistula. Ann Surg 1954; 140 (03) 381-395
    CrossrefPubMedSearch in Google Scholar
  • 21 Okada A, Kamata S, Imura K. et al. Anterior sagittal anorectoplasty for rectovestibular and anovestibular fistula. J Pediatr Surg 1992; 27 (01) 85-88
    CrossrefPubMedSearch in Google Scholar
  • 22 Javid PJ, Barnhart DC, Hirschl RB, Coran AG, Harmon CM. Immediate and long-term results of surgical management of low imperforate anus in girls. J Pediatr Surg 1998; 33 (02) 198-203
    CrossrefPubMedSearch in Google Scholar
  • 23 Elrouby A, Waheeb S, Koraitim A. Anterior sagittal anorectoplasty as a technique for the repair of female anorectal malformations: a twenty two-years-single-center experience. J Pediatr Surg 2020; 55 (03) 393-396
    CrossrefPubMedSearch in Google Scholar
  • 24 Reck-Burneo CA, Skerrit C, Dingemans A. et al. Primary or redo posterior sagittal anorectoplasty without a stoma: to feed or not to feed?. Eur J Pediatr Surg 2019; 29 (02) 150-152
    Thieme ConnectPubMedSearch in Google Scholar
  • 25 Martynov I, Gosemann JH, Hofmann AD. et al. Vacuum-assisted closure (VAC) prevents wound dehiscence following posterior sagittal anorectoplasty (PSARP): an exploratory case-control study. J Pediatr Surg 2021; 56 (04) 745-749
    CrossrefPubMedSearch in Google Scholar
  • 26 Karakus SC, User IR, Akcaer V, Ceylan H, Ozokutan BH. Posterior sagittal anorectoplasty in vestibular fistula: with or without colostomy. Pediatr Surg Int 2017; 33 (07) 755-759
    CrossrefPubMedSearch in Google Scholar
  • 27 Gupta A, Agarwala S, Sreenivas V, Srinivas M, Bhatnagar V. Primary definitive procedure versus conventional three-staged procedure for the management of low-type anorectal malformation in females: a randomized controlled trial. J Indian Assoc Pediatr Surg 2017; 22 (02) 87-91
    CrossrefPubMedSearch in Google Scholar