Primary Posterior Sagittal Anorectoplasty in male neonates with Anorectal Malformations: A tertiary care hospital experience

Background: The conventional surgical management for a male neonate with intermediate Anorectal Malformation (ARM) involves three stages – the creation of a diversion stoma in the neonatal period, a definitive pull-through procedure/ Posterior Sagittal Anorectoplasty (PSARP) followed by stoma closure. With this background, we present our experience with Single-stage primary definitive repair in selected male neonates with ARM. Methods: Medical records of male ARM cases managed from 2016 to 2018 were reviewed. Male neonates who underwent primary PSARP were analysed retrospectively. Results: A total of 35 records were found, out of which 12 male neonates underwent primary PSARP. The median gestational age and birth weight were 36.7 weeks and 2.75 kg respectively. Fistula with urinary tract was documented in all. The mean operative time was 65 minutes +/- 15 minutes. Two neonates had minor superficial surgical site infection at neo-anus. Anal dilatations were started after 2 weeks. At follow-up period of 3 years, 11 patients were continent; one patient had constipation with pseudo-incontinence which was successfully being managed by bowel management programme. Conclusions: A primary definitive procedure is feasible when performed on carefully selected male neonates with ARM and also avoids the morbidity of stoma and multiple surgeries and follow-up visits to hospitals.

Comparative study of outcome following primary posterior sagittal ano-rectoplasty and primary anterior sagittal ano-rectoplasty for vestibular fistula

Background: To compare the postoperative complications and bowel function following primary PSARP and primary ASARP.Methods: This prospective study was carried out over a period of 4 years. Patients above 4 months, who needed surgical repair for vestibular fistula were included in study. They were randomly allocated into PSARP group and ASARP group. After surgical intervention, patients of both groups were compared with respect to post-operative complications, voluntary bowel control, constipation, need for laxatives.Results: 44 patients were enrolled in the study. Of these, 22 patients were allocated to primary PSARP group while remaining patients underwent ASARP. One patient from each group was lost to follow‑up and hence, excluded from the final analysis. The two groups were comparable with respect to age, maturity at birth, weight at the time of surgery, blood investigations. Total 16 patients had associated congenital anomalies. During the postoperative period, four patients from PSARP group and two patients from ASARP group had superficial wound infection of perineal incision which was managed conservatively. One patient in PSARP group had a major breakdown of perineal wound with retraction of pulled rectum which required colostomy. There was no recurrence of fistula in any patient. No patient had stenosis of neo-anus or anterior displacement of rectum. Functional assessment of bowel function was done in 25 patients who completed 3 years of age. Voluntary bowel movements were observed in 75% of cases in the ASARP group compared to 38 % in PSARP group. 15% patients of PSARP group and 7.5% patients with ASARP had soiling. Though the difference was not statistically significant, nearly 38% of the patients after PSARP, needed laxative for normal bowel habit compared to 8% patients in ASARP group.Conclusions: ASARP promises many advantages in the treatment of vestibular fistula in comparison to PSARP. Comparable post-operative complications, good cosmetic results, excellent continence with less need for laxatives are the advantages of ASARP.

Use of biofeedback (BFB) in the treatment of fecal incontinence after surgical correction of anorectal malformations by posterior sagital anorectoplasty (PSARP)

OBJECTIVE: To evaluate biofeedback(BFB)responses to rehabilitation techniques and physical exercises in incontinent or partially continent anorectal malformations patients after posterior sagital anorectoplasty (PSARP). DESIGN: Prospective study. SETTING: Pediatric Surgery - Department of Surgery - UNIFESP-EPM. PATIENTS:The authors report on 14 patients with anorectal malformations (4 with partial fecal incontinence after primary PSARP; 6 with fecal incontinence after primary PSARP; 3 with partial fecal incontinence after secondary PSARP; and 1 with fecal incontinence after secondary PSARP). All patients were rehabilitated via a BFB program of exercises in order to improve the function of the anal sphincteric muscular complex for a period of 1 -3 years. MAIN OUTCOME MEASURE: Clinical and manometric control. RESULTS: After BFB, of 4 partially continent patients after primary PSARP, 3 became continent; of 6 incontinent patients after primary PSARP, 4 became continent; of 3 partially continent patients after secondary PSARP, 1 became continent,1 showed no improvement and 1 became incontinent (infection + abscess + fibrosis + important anorectal stenosis). The incontinent patient after secondary PSARP showed no improvement. CONCLUSION: The authors concluded that BFB, used at the appropriate time with patient collaboration, is an important complement to the anatomical reconstruction of anorectal malformations in order to achieve good development and contractile functioning of the sphincteric muscular complex.