The outcome of two stage repair in anorectal malformations with rectovestibular fistula.

Wound infection and dehiscence after recto vestibular fistula repair may affect the fecal continent mechanisms. A significant number of children with anorectal malformations have long term social, economic and psychological problems due to fecal incontinence. The role of protective colostomy should not be under estimated especially when you are treating the children from poor socioeconomic settings with compromised nutritional status. Objectives: The aim of this study was to evaluate the outcome of two stage limited posterior sagittal anorectoplasty with protective colostomy in female patients of congenital recto vestibular fistula. Study Design: Prospective study. Settings: Department of Pediatric Surgery, DHQ Teaching Hospital Sahiwal. Period: January 2016 to December 2018. Material & Methods: Thirty four girls with anorectal malformation and recto vestibular fistula underwent two stage anorectoplasty. Divided sigmoid colostomy and limited posterior sagittal anorectoplasty was performed in first stage. Six to eight weeks later stoma was closed in second stage. All the patients were evaluated for fecal continence, constipation, bowel function and complications of stoma formation, definite procedure and stoma closure. Results: The age distribution of patients at the time of surgery ranged from 9 months to 5 years (mean 27.32 months). During the first stage of repair, three patients (8.82 %) developed wound infection. Mucosal prolapse was seen in two patients (5.88%). Anal stenosis was noticed in one patient (2.94%). Seven patients (20.58%) developed peri stoma skin excoriation. Stoma prolapse was observed in three patients (8.82%). Four patients (11.76%) developed wound infection after colostomy closure. During the follow up period, constipation was reported in five patients (14.70%) and soiling in one patient (2.94%). Conclusion: Two stage correction of congenital recto vestibular fistula under the cover of colostomy is safe strategy. It is strongly recommended in a setup with limited resources and weak infrastructure. It is also useful for patients from poor socioeconomic settings.

Algorithm for Surgical Treatment of Children with Hirschsprung’s Disease

Hirschsprung’s disease requires surgical treatment. Depending on the form of aganglionosis and severity of pathology, open or minimally invasive, one-stage or multi-stage radical surgery may be used. The objective of the research was to develop an algorithm for surgical treatment of children with Hirschsprung’s disease. Materials and methods. The analysis of surgical treatment of 1,129 children with different forms of Hirschsprung’s disease aged from birth to 18 years over the period 1980-2018 was conducted. All the patients underwent both traditional and minimally invasive radical surgery. Results and discussion. The patients were divided into three groups; each group was characterized by modernization of surgical methods, as well as intensification of diagnostics for early detection of such patients. Radical surgery without a protective colostomy was used in 773 (68.46%) cases, while in 356 (31.53%) cases, a protective colostomy was created. Due to the intensification of diagnostics that markedly contributed to early detection of patients with various forms of Hirschsprung’s disease, during each study period, there was observed a dramatic decrease in the number of stoma patients with a significant increase in the number of children diagnosed with Hirschsprung’s disease: from 68.54% (1980-1992) to 37.93% (1993-2010) and 12.00% (2011-2018). Conclusions. Timely diagnostics contributes to early detection of children with different forms of Hirschsprung’s disease. In uncomplicated forms of Hirschsprung’s disease, it is reasonable to perform one-stage radical surgery, namely the resection of the aganglionic segment and the affected colon segment followed by colorectal anastomosis. In severe Hirschsprung’s disease, two-stage surgery should be used: creation of a protective colostomy (the first stage) and radical surgery (the second stage). In some cases, in colectomy, three-stage surgical approach is needed, namely the creation of a protective colostomy (the first stage), radical surgery (the second stage) and protective colostomy closure (the third stage).

Treatment of Fournier's Gangrene with Combination of Vacuum-Assisted Closure Therapy, Hyperbaric Oxygen Therapy, and Protective Colostomy

Fournier's gangrene is a rare process which affects soft tissue in the genital and perirectal area. It can also progress to all different stages of sepsis, and abdominal compartment syndrome can be one of its complications. Two patients in septic shock due to Fournier gangrene were admitted to the Intensive Care Unit of Emergency Department. In both cases, infection started from the scrotum and the necrosis quickly involved genitals, perineal, and inguinal regions. Patients were treated with surgical debridement, protective colostomy, hyperbaric oxygen therapy, and broad-spectrum antibacterial chemotherapy. Vacuum-assisted closure (VAC) therapy was applied to the wound with the aim to clean, decontaminate, and avoid abdominal compartmental syndrome development. Both patients survived and were discharged from Intensive Care Unit after hyperbaric oxygen therapy cycles and abdominal closure.

Correlation between Radiotherapy and Suture Fistulas following Colo-anal Anastomosis for Carcinoma of the Rectum Evaluation of 152 Consecutive Patients

Introduction The aim of this study was to evaluate the prevalence of suture fistulas and their possible correlation with adjuvant therapy in patients who underwent colo-anal anastomosis and J pouch reconstruction with a protective colostomy. The reliability of the radiological screening and monitoring program was also verified. Methods One hundred and fifty-two consecutive patients were evaluated radiologically with water-soluble radio-opaque contrast enema before surgery for closure of the protective colostomy. Fifty-seven patients were treated with surgery alone (group A) and 95 patients received adjuvant treatment (group B). Results A total of 54 fistulas were seen: 17 in group A (28.9% of patients in group A) and 37 in group B (38.9% of patients in group B). Six fistulas involved the rectovaginal septum. All fistulas were managed medically. The time to resolution was 30 days in 76.4% of patients in group A and about 50 days in 82% of patients in group B. Rectovaginal fistulas always took much longer to heal in both groups and failed to heal in two of the four cases in group B. Conclusions Two factors appear to contribute to the high prevalence of fistulas in this series: extension of radiological screening to all operated patients and adjuvant radiotherapy. However, the postoperative course was not compromised by radiotherapy in that these fistulas resolved with medical treatment alone, although healing took longer. The incidence of rectovaginal fistulas was substantially the same in the two groups, but two of the four occurring in group B did not heal. Postoperative monitoring with water-soluble contrast enema appears to be the diagnostic procedure of choice because it is well tolerated, non-invasive and a reliable aid in planning surgical bowel recanalization since no false negative cases were detected clinically after closure of the colostomy.

Transsphinctericanorectal reconstruction of ambiguous genitalia: an innovative approach to neovaginoplasty, pioneer in Brazil

The authors, based upon previous experience in the treatment of ten children with cloacal abnormalities, among which two with female pseudohermaphroditism with cloaca, hereby present a pioneer experience in Brazil, with the "posterior sagittal transsphinctericanorectalurethrovaginoplasty" a surgical approach to neovaginoplasty described by "Cripps/Peña", which was utilized for the reconstruction of the genitalia of three intersexuated adolescents with protective colostomy, who presented an urogenital sinus, high vaginal implantation and a normal rectum. One patient was an adrenal female pseudohermaphrodite and two were male pseudohermaphrodites. The authors present a brief report on the three cases, describe the surgical procedure, relate on the anatomy of the urogenital sinus and discuss surgical indications, diagnosis and results, comparing them to the reviewed international literature.