Post-operative strictures in anorectal malformation: trends over 15 years

Abstract

The laparoscopic-assisted pull-through involves tunnelling the sphincter muscle complex. We found that often the tunnels were not wide enough, resulting in narrowing not just at the ano-cutaneous junction but also at the deeper level. 50% developed strictures. We have modified our technique by ensuring that the tunnels are generous enough to allow the rectum to be pulled through without any resistance. ISSA unfortunately resulted in 30% of our patients developing strictures. This approach, started in 2004, was, therefore, abandoned in 2013. The standard Pena's PSARP, with or without a laparotomy, has stood the test of time. Any modification of this approach must be carefully thought through and audited meticulously. Strictures can cause significant morbidity, which may need several revisions, and the resulting redo anoplasties run the risk of sphincter damage, ironically which the newer modifications of ISSA were trying to conserve.

The Role of Laparoscopy in Anorectal Malformations

“…Seven articles compared PSARP with LAARP, while other articles discussed specific laparoscopic approaches or reported series. [3][4][5][6][7][8][9][10] One article discussed laparoscopic colostomy creation in the setting of LAARP. 11 Three articles reported the use of laparoscopy for the mobilization of the rectal component in cloaca repairs.…”

“…Eight articles compared results between laparoscopy and the posterior sagittal approach. [4][5][6][7][8][9]22 The outcomes variably evaluated by the authors were: perioperative clinical results, rectal manometry, magnetic resonance imaging (MRI), length of stay, and complications. Ten articles described the radiographic features of the sacrum/spinal cord [7][8][9][10][11][23][24][25][26][27][28][29] and five reported a sacral ratio calculation.…”

“…A single-institution review of the LAARP cases that involved strictures found many of them long segment as the tunnels or an internal sphincter-sparing approach where the tunnel was not wide enough, resulted in narrowing both at the anocutaneous junction and also at the deeper sphincter levels. 4 A slightly larger perineal incision can avoid this problem.…”

Errors and сomplications in the treatment of children with anorectal malformations

“…Наиболее освещены вопросы осложнений после аноректопластики -выстояние слизистой низведенной кишки (19,2 %), стомирования -эвагинация и стенозирование стом (по 6 %) [3]. Некото-рыми авторами отмечается снижение частоты ректального выпадения при лапароскопических методиках низведения кишки, при этом описано увеличение частоты стенозов ануса после видеоассистированных операций [4,5].…”

“…Отдаленный катамнез пациентов АРМ в нашей стране привлекает интерес исследователей, но зачастую не превышает 1-2 лет [7,8]. Зарубежные коллеги выделяют ранние послеоперационные осложнения -стеноз ануса (14-16 %), раневую инфекцию (7-24 %), ректальный пролапс (3,8-27 %), рецидивирующие ректо-урогенитальные свищи (1-16 %), задний дивертикул уретры (остаточная кишечная культя -2 %) [5,[9][10][11]. Неудовлетворительные функциональные результаты (запор, недержание и псевдонедержание кала) относят к поздним осложнениям комплексного (оперативного и консервативного) лечения и их считают основной составляющей низкого уровня качества жизни подрастающих детей с АРМ [12,13].…”