Introduction. Anorectal malformations are one of the most numerous groups of proctologic pathology in children. The incidence is 1 per 5,000 live births. Perineal ultrasound, distal colostography, and MRI of the pelvic organs and sacrococcygeal region are used to clarify the anatomico-topographic features of the malformation and identify concomitant malformations (presacral masses, distal spinal cord pathology). This article presents a clinical case of surgical treatment of an 11-year-old girl who underwent primary surgery for anorectal malformation with rectovestibular fistula in infancy. In the postoperative period for 10 years, the parents practically did not carry out rehabilitation therapy. These factors led to persistent decompensation of the lower intestine in the form of a giant megarectum, which required repeated anorectoplasty with resection of pathologically dilated parts of the intestinal tube. The article presents description of the repeated surgery with intraoperative electromyoidentification of the perineal muscles, data of follow-up 9 months after the repeated anorectoplasty with instrumental diagnostic methods (irrigography, functional study of the closing apparatus of the rectum).Discussion. This clinical observation illustrates complications following surgical treatment of anorectal malformation with rectovestibular fistula. Lack of intraoperative electromyoidentification of the muscles during primary anorectoplasty often resulted in ectopia of the neoanus relative to the center of the perineal muscle center. This circumstance was one of the causes of persistent chronic constipation in the postoperative period.Conclusion. The use of electromyostimulation during primary proctoplasty for reliable determination of the sphincter-levator complex topography is mandatory. Long sequential rehabilitation in the postoperative period including neoanus bougienage, provision of regular full defecation, physiotherapeutic treatment, as well as regular follow-up examination in the in-patient department is also an integral part of the treatment.
Rectal prolapse (RP) is one of the most expected complications following the treatment of anorectal malformations that occurs in 3.8% to 60% of cases. The main method of surgical treatment of RP is anoplasty with a recurrence rate after surgery of up to 33%. The authors describe the indications, technique and results of transanal rectal mucosectomy and muscular plication (TRMMP) proposed by Dr. Luis De La Torre-Mondragon, MD, Pediatric Colorectal Surgeon with the Children's Hospital Colorado (CHCO), Aurora, Colorado, United States, for the treatment of RP in children with anorectal malformations (AM). Materials and methods used: in a retrospective analysis of 234 patients with AM, 8 patients with RP (all males) were identified. In 2 patients, a displacement of the rectum was detected, and subsequently they underwent the posterior sagittal anorectoplasty (PSARP). Another 6 patients underwent the TRMMP. Results: all patients had previously undergone the open surgery without PSARP. The average age of patients at the time of surgery was 4.6 years (Q1-2.5, Q3-7.9; SD-2.2; min/max 2.0-5.0; 95% CI: 2.1-5.5). In all patients, the RP length averaged 2.3 cm (Q1-1.5, Q3-3.9; SD-0.9; min/max - 1.6-4.0; 95% CI: 1.4-3.3). There were no intraoperative and postoperative complications. There were no relapses of RP and stenoses of anastomoses during the dynamic follow-up after surgery for 7.6 months recorded as well (Q1-5.0, Q3-10.9; SD-2.4; min/max - 5.0-11; 95% CI: 5.1-10.2). Conclusion: the authors’ first experience confirms the efficacy of TRMMP in RP in children with AM.
The lecture presents modern information about embryogenesis, associated anomalies, diagnosis, and treatment of various forms of anorectal malformations (ARM) in children. During the initial examination of ARM children the authors recommend the following sequence of actions for a neonatologist and a surgeon: catheterization the esophagus in order to exclude combined esophageal atresia; survey radiography of the abdominal organs in direct or lateral projections to exclude concomitant duodenal atresia, dilated intestinal loops and primary assessment of the condition of the spine and sacrum; echocardiography to detect concomitant heart and large vessel defects (occur in 30% of ARM newborns), Ultrasound of the kidneys and bladder. A special X-ray study to determine the location of the intestine al atresia is carried out by a pediatric surgeon no earlier than 18-24 hours after birth in newborns without an anus on the perineum. It is believed that after this period of time, the gas will fill the atresized part of the intestine, which is determined on the side image at the level of the coccyx or sacrum or in the abdominal cavity, depending on the type of pathology. To determine the prognosis of the functional state of the pelvic organs before surgery, it is recommended to determine the sacral index, since a visual assessment of the state of the sacrum and coccyx (counting the number of vertebrae) in most cases does not allow a quantitative assessment of the detected changes. The bowel management program provides training for the patient’s parent or child on how to empty the bowel in order to achieve a “clean” period (without constipation and fecal smearing) during the day. The schedule is developed individually for each patient, usually within one week. The issues of postoperative rehabilitation of patients at the stage of treatment in the clinic are discussed.
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