Single-stage repair of vestibular and perineal fistulae without colostomy

Purpose

This retrospective study was undertaken to evaluate the feasibility of primary anorectoplasty without a covering colostomy using the anterior sagittal anorectoplasty (ASARP) or posterior sagittal anorectoplasty (PSARP) technique in patients having vestibular and perineal fistulae, its complications, results, and remote outcome in our institute.

Methods

From January 2000 to June 2007, patients with vestibular and perineal fistulae subjected to single-stage surgical correction at our institute were reviewed retrospectively from the data available in hospital records and follow-up complaints of patients and their parents in the outpatient department. Patients who had undergone a staged repair were excluded from the study. All patients were assessed for immediate and delayed complications including continence of the neorectum.

Results

From January 2000 to June 2007, 123 patients having vestibular (94) and perineal fistulae (29), age range from 28 days to 10 years, were subjected to primary repair either by the ASARP (34) or PSARP (89) technique. Follow-up period ranged from 3 months to 7 years. Mortality was nil. Constipation (25.68%) was the major long-term problem. Incontinence occurred in 1 patient (1.85%), who also had associated sacral agenesis. A total of 98.15% of patients were continent with stool frequency of 1 to 4 per day. Recurrence of fistula (0.81%), anal stenosis (6.76%), mucosal prolapse (2.70%), and anterior migration of the neoanus (1.35%) were the other major problems. Other minor problems like wound infection, superficial wound dehiscence, transient constipation, and diarrhea, etc, were successfully managed by local wound care, antibiotics, laxatives, enema, anal dilatation, and dietary changes.

Conclusion

Primary anorectoplasty either by PSARP or ASARP is feasible in vestibular and perineal fistulae without covering colostomy. Associated sacral agenesis/hypoplasia, redundant rectosigmoid or pouch colon, and wound infections with dehiscence are the major confounding factors affecting overall outcome. Better outcome in terms of continence can be achieved by careful surgical technique and follow-up along with proper toilet training. Complication rate was greater in cases of vestibular fistula than of perineal fistula, regardless of technique used. Some sort of laxatives and enema are often required. Dilatation of the neoanus for varying periods is also needed.     

Single-stage repair for rectovestibular fistula without opening the fourchette

Background

Anorectal malformations are one of the most common congenital defects. This study is conducted to demonstrate new technique for treatment of rectovaginal fistula without disturbing the fourchette through posterior sagittal approach.

Method

All the patients of rectovestibular fistula admitted after the neonatal age were treated with posterior sagittal anorectoplasty without opening the fourchette. The results were evaluated for cosmetic appearance and anal continence.

Result

A total of 40 patients were included in our study. All patients were more than 1 month old. Operative time ranges from 70 to 150 minutes. The cosmetic appearance was good. Anal continence was good in 72% cases and fair in 20% cases. Fifteen percent of patients had minimal constipation and 7.5% patients had mucosal prolapse.

Conclusion

Single-stage repair for vestibular anus through posterior sagittal anorectoplasty without opening fourchette has a good cosmetic appearance and good anal continence.     

Outcome of patients after single-stage repair of perineal fistula without colostomy according to the Krickenbeck classification

Purpose

The aim of the study is to assess the characteristics and outcome of anorectal malformation (ARM) patients who underwent single-stage repair of perineal fistula without colostomy according to the Krickenbeck classification.

Methods

From 2002 to 2013, twenty-eight males and four females with perineal fistula who underwent single-stage repair without colostomy in our institute were included in this study. Patients with perineal fistula who underwent staged repair were excluded. Demographics, associated anomalies, and operative complications were recorded. The type of surgical procedures and functional outcome were assessed using the Krickenbeck classification.

Results

Six patients had associated anomalies, including two patients with renal, two with cardiac, one with vertebral, and one with limb abnormalities. Thirteen patients underwent perineal operation, and fourteen patients underwent anterior sagittal approach in the neonatal period. One patient underwent anterior sagittal approach, and four patients underwent PSARP beyond the neonatal period. One patient had an intra-operative urethral injury and one a vaginal injury. Complications were not associated with the type of surgical procedure (p = 0.345). All perineal wounds healed without infection. By using the Krickenbeck assessment score, all sixteen children older than five years of age had voluntary control. One patient had grade 1 soiling, and no patient had constipation.

Conclusions

Single-stage operation without colostomy was safe with good outcomes in patients with perineal fistula. The use of Krickenbeck classification allows standardization in assessment on the surgical approach and on functional outcome in ARM patients.     

Laparoscopy and its use in the repair of anorectal malformations

Introduction

Laparoscopy has been used for the treatment of anorectal malformations (ARMs) in an attempt to be less invasive and with the hope that it would result in a better functional outcome. There remains a significant debate about whether these expectations have been fulfilled.

Methods

Seventeen patients with ARM for whom laparoscopy was used were retrospectively reviewed. Six were operated on primarily by the authors, and 11 cases were referred after a laparoscopic repair performed elsewhere. In addition, a literature review was performed looking for evidence of less invasiveness and improved functional results in patients operated on laparoscopically.

Results

The diagnosis was imperforate anus with a rectobladder neck fistula in our 6 cases with the fistula ligated laparoscopically in each case. In 1 patient, the malformation was repaired entirely using laparoscopic technique. The other 5 patients had a laparoscopically assisted repair because we had to open the abdomen to taper a dilated rectum in 2, mobilize a very high rectum in 2, and take down a distal colostomy stoma in 1. Eleven patients were referred with a variety of problems after a laparoscopic repair done elsewhere for rectal stricture (5), rectal prolapse (4), recurrent rectourethral fistula (3), rectal mislocation (3), failed attempted repair leading to fecal incontinence (1), and a posterior urethral diverticulum (1). Our literature review included 47 references (involving 323 patients) published between 1998 and 2010. All studies showed that laparoscopic repair of ARMs is feasible. The review, however, did not provide evidence of less invasiveness or improved functional results.

Conclusions

Laparoscopy for ARM is a less invasive procedure when compared with those operations that would have previously required a laparotomy (rectobladder neck fistula). In cases of rectoprostatic fistulae, the laparoscopic approach is feasible and avoids a lengthy posterior sagittal incision. There is no evidence that the laparoscopic approach is a less invasive procedure for other types of ARMs. In cases of rectobulbar fistula, congenital anal stenosis, perineal fistula, ARM without fistula, the evidence suggests that it may be lead to more complications. There is no evidence in the literature demonstrating better functional results in cases of ARM operated on laparoscopically.     

Rectovestibular fistula—rarely recognized associated gynecologic anomalies

Introduction

Vestibular fistulas are the most common anorectal malformations (ARMs) in females. Associated gynecologic defects are rarely mentioned in the literature but may have serious clinical implications if undetected. The definitive repair of the ARM offers an opportunity for diagnosis and treatment of these conditions.

Methods

Two hundred seventy-two patients with vestibular fistula were retrospectively reviewed, with emphasis on gynecologic defects.

Results

Forty-eight patients (17%) had 83 gynecologic anomalies. Fourteen patients had a vaginal septum, all with 2 uterine cervices. All septa were resected at the main repair. Twenty-six patients had no vaginal opening. Twenty of them had absent vagina. Eighteen of those had an absent uterus. Patients with absent vagina underwent vaginal replacement with distal rectum (12), sigmoid (6), and ileum (2). Six patients had a patent upper vagina; 3 reached the perineum after mobilization and 3 required replacement; 2 with sigmoid and 1 with rectum.

Conclusion

Vaginal septa are easily diagnosed and can be resected during the repair of the vestibular fistula. The presence of 2 cervices has important obstetric implications. Absent vagina requires a technically demanding repair, with special preoperative planning. Vaginoscopy or careful inspection should precede surgical reconstruction.     

Management of H-type rectovestibular and rectovaginal fistulas

Introduction

H-type rectovestibular or rectovaginal fistulas are rare entities in the spectrum of anorectal malformations seen in North America. Management options described in the literature have included perineal repair, anterior perineal anorectoplasty, vestibuloanal pull-through, and limited or formal posterior sagittal anorectoplasty, with a reported recurrence rate of 5% to 30%. We describe our approach and outcome in the management of these patients.

Methods

In a series of 1170 females with anorectal malformation, we cared for 8 patients who had an H-type rectovestibular or rectovaginal fistula and reviewed their clinical presentation, diagnosis, operative technique, and postoperative course.

Results

The patients' presenting symptoms included passage of stool per vagina (6), constipation (3), labial abscess (1), and recurrent urinary tract infection (1). There was associated anorectal stenosis in 3 patients. The remaining 5 patients had normal anal openings. Endoscopy was not helpful in locating the fistulas, but the fistulas were all demonstrated on direct inspection under anesthesia. The fistula was located in the vestibule (4), vagina (3), or labia (1). One patient had an associated presacral mass. Two patients had been operated on twice previously using a perineal repair and a protective colostomy and presented with third recurrences. In 5 cases, a posterior sagittal approach was used, placing sutures circumferentially around the fistulous opening on the rectal side, ligating the fistula, and pulling down a normal segment of rectum to be placed in front of the repaired vaginal wall. In our last 3 cases, we performed a transanal mobilization of the anterior rectal wall, leaving the perineal body intact. After our repairs, the patients have been followed up for 3 months to 15 years with a median of 15 months, and we have seen no recurrences.

Conclusions

In addition to vaginal passage of stool, an H-type fistula should be suspected when there is a labial abscess in an infant, and an associated anal stenosis or presacral mass must be checked for. Direct inspection is the key, with a careful look in the vestibule, because endoscopy may miss the fistula. The essential technical point for repair is to get healthy anterior rectal wall to cover the area of fistula on the posterior vagina. A transanal approach, leaving the perineal body intact, is an excellent option for this repair.     

Single-stage management of all pouch colon (anorectal malformation) in newborns

Background/Purpose

The standard procedure in the management of pouch colon is the staged procedure (SP), which has well-known disadvantages. We believe that staging is unnecessary and primary single-stage procedure (PSSP) can be done.

Methods

Patients with pouch colon who underwent PSSP (102 cases from 1997 to 2003) and SP (98 cases from 1991 to 1997), 63 and 42 of whom, respectively, were in regular follow-up for more than 3 years, were evaluated.

Results

In PSSP, male/female ratio was 94:8; in SP, 89:9. Mean age in PSSP was 4.6 days and in SP 26 months. The distribution of cases into types I, II, III, and IV was 10, 24, 14, and 15 in PSSP, and 8, 20, 10, and 4 in SP, respectively. The ratio of PSSP/SP for total pouch colon (I and II) was 34:28 and for partial pouch colon (III and IV) was 29:14. The ratio of PSSP/SP in terms of continence, mortality, and cost was 75:48, 11:47, and 1:4, respectively.

Conclusions

Primary single-stage procedure gives better continence and cosmesis, with low morbidity and mortality at a low cost, and hence is recommended.     

Long-term results of anterior sagittal anorectoplasty for the treatment of vestibular fistula

Purpose

Vestibular fistula is the commonest anorectal malformation in the female child. This article reports the treatment and long-term follow-up of 1206 patients of vestibular fistula treated by anterior sagittal anorectoplasty (ASARP) in a single center for 38 years.

Material and Methods

All patients of vestibular fistula admitted and operated on at the Department of Pediatric Surgery, King George Medical University (Lucknow, UP India), from 1970 were included in the study; the age ranged from 2 days to 40 years. The diagnosis was made by clinical examination. We differentiated between anovestibular fistula (AVF) and rectovestibular fistula (RVF) in that the latter is a longer narrow fistula closely applied to the posterior wall of the vagina. Preoperative investigations included hemogram and blood glucose. Echocardiography was done in those patients showing a physical sign of cardiac anomaly. All patients were operated on in the lithotomy position by ASARP; this was done without colostomy in 1169 patients. In 6 patients, preliminary colostomy was done because of excessive perineal excoriation, and 31 others had colostomy done elsewhere. The striated muscle complex was delineated by electrostimulation, and anoplasty was performed after anchoring the rectum within the muscle complex. Washing of the perineum after passage of stools with application of povidone-iodine ointment constituted the local care. Intravenous antibiotics were administered for 48 hours and oral antibiotics (including metronidazole) for 5 days. The patient was discharged home by the fifth day.

Results

Follow-up ranges from 3 months to 19 years; uneventful postoperative recovery was seen in 1147 patients. They had normal growth and development, normal appearance of the perineum, and a normal quality of life. Complications were seen in 60 patients (5%) of which 42 had AVF and 18 had RVF. Eight patients had postoperative wound disruption that was minor in 4 and required colostomy in the other 4. Four patients had recurrence of vestibular fistula thus creating an iatrogenic perineal canal; this could be repaired by a second ASARP in 3 patients and required colostomy and PSARP in one child. Anal stenosis was seen in 11 patients; this was treated by dilatation alone in 6 and required posterior Y-V plasty in 5. The rate of complications in RVF was lower than AVF probably because of lesser number of patients; there was no difference in stooling pattern or continence between uncomplicated patient of RVF and AVF; however, fecal staining was seen in all patients undergoing revision surgery for complications.

Conclusions

This experience with ASARP showed a good result in 95% patients in a single-stage procedure. The technical ease and minimal preoperative and postoperative measures make ASARP the procedure of choice for vestibular fistula in females at all ages. Until sufficient experience is gained, it may be safer to operate on patients with RVF under cover of a protective colostomy.     

Long-term functional outcome and quality of life in patients with high imperforate anus

Purpose

Anorectal malformations (ARMs) are associated with a large number of functional sequale that may affect a child's long-term quality of life (QOL). The purposes of this study were to better quantify patient functional stooling outcome and to identify how these outcomes related to the QOL in patients with high imperforate anus.

Methods

Forty-eight patients from 2 children's hospitals underwent scoring of stooling after 4 years of life. Scoring consisted of a 13-item questionnaire to assess long-term stooling habits (score range: 0-30, worst to best). These results were then correlated with a QOL survey as judged by a parent or guardian.

Result

Mean (SD) age at survey was 6.5 (1.6) years. Comparison of QOL and clinical scoring showed no signficant difference between the 2 institutions (P > .05). There was a direct correlation between the QOL and stooling score (Pearson r² = 0.827; β coefficient = 24.7, P < .001). Interestingly, functional stooling scores worsened with increasing age (Pearson r² = 0.318, P = .02). Patients with associated congenital anomalies had a high rate of poor QOL (44% in poor range; P = .001). Stooling scores decreased significantly with increasing severity/complexity of the ARM (P = .001).

Conclusion

A large number of children experience functional stooling problems, and these were directly associated with poor QOL. In contrast to previous perceptions, our study showed that stooling patterns are perceived to worsen with age. This suggests that children with ARMs need long-term follow-up and counseling.     

Cloaca reconstruction: a new algorithm which considers the role of urethral length in determining surgical planning

Background

Cloacal malformations represent a uniquely complex challenge for surgeons. The surgical approach to date has been based on the common channel (CC) length with two patient groups considered: less than or greater than 3 cm, which we believe is an oversimplification. We reviewed 19 patients, referred after surgery done elsewhere. Eight had postoperative urinary complications, 3 had constant urinary leakage and had been left after surgery with a urethra < 1 cm, .5 with an original 3 to 5 cm common channel, who had undergone total urogenital mobilization (TUM), experienced peri-operative urethral loss needing a vesicostomy, and later, a Mitrofanoff. These patients together with a review of the cloacal and urological literature led us to design a new algorithm where urethral length is a key determinant for care.

Double termination of the alimentary tract in females: a report of 12 cases and a literature review

Twelve female infants with double termination of the alimentary tract were reported. One patient had a high rectovaginal fistula, but in the other 11 cases the tract opened into the bowel uniformly at the level of the levator ani (anorectal-vestibular fistula). In these patients, diagnosis of the anatomical level of the fistula was made definitely with our radiological technique. Excision of not only the fistulous tract but also the anterior half of the rectum below the fistula is essential to achieve a cure without recurrence. The pathogenesis of this condition is discussed and the pertinent literature reviewed.     

Diagnosis and management of a remnant of the original fistula (ROOF) in males following surgery for anorectal malformations

PurposeA complication of the surgical management of anorectal malformations (ARMs) is a retained remnant of the original fistula (ROOF) formerly called a posterior urethral diverticulum (PUD). A ROOF may have multiple presentations or may be incidentally discovered during the work-up of ARM after previous surgery. We sought to define the entity and the surgical indications for excision of a ROOF when found.MethodsWe performed a retrospective cohort study of all male patients who presented to our center following previous repair for ARM at another institution, who came for evaluation of problems with urinary and/or fecal continence, from 2014 to 2017. Charts were reviewed for symptoms, original type of malformation, preoperative imaging, treatment, and postoperative follow-up.ResultsOf 180 referred male patients, 16 had a ROOF. 14 underwent surgical repair to address this and for other redo indications, and 2 did not require intervention. 13 patients had an additional reason for a redo such as anal mislocation or rectal prolapse. Indications for ROOF excision were urinary symptoms (e.g. UTI, dribbling, passage of mucous via urethra, stone formation), to make a smoother posterior urethra for intermittent catheterization, or for prophylactic reasons. Patients were repaired at an average age of 4.2 years, using a PSARP only approach with excision of the ROOF for all except one patient who needed a laparotomy due to abdominal extension of the ROOF. No patient needed a colostomy. The original ARM repairs of the patients were PSARP (9), laparoscopic assisted (4) and abdominoperineal pullthrough (3). Preoperative evaluation included pelvic MRI, VCUG, and cystoscopy. The ROOF was visualized on 14 of 16 MRIs, 10 of 14 VCUGs, and 14 of 15 cystoscopies. Urinary symptoms associated with a ROOF and ease of catheterization were improved in all repaired cases.ConclusionPatients not doing well from a urinary or bowel standpoint post ARM pull-through need a complete evaluation which should include a check for a ROOF. Both modalities MRI and cystoscopy are needed as a ROOF can be missed on either alone. A VCUG was not reliable in identifying a ROOF.Excision is needed in patients to improve urinary symptoms associated with these lesions and to minimize the small but theoretical oncologic risk present in a ROOF.Level of evidenceLevel III.     

Earlier appearance and higher incidence of the rectoanal relaxation reflex in patients with imperforate anus repaired with laparoscopically assisted anorectoplasty

Background: This study aimed to evaluate clinically and manometrically the anorectal function of patients with imperforate anus after repair with laparoscopically assisted anorectoplasty (LAR), as compared with the function of patients after undergoing the conventional method, posterior sagittal anorectoplasty (PSARP). Methods: The defecation status and anorectal manometry of patients with high or intermediate type imperforate anus repaired with LAR (n = 9) and age-matched patients repaired with PSARP (n = 13) were assessed and compared during the first year of postoperative follow-up evaluation. The defecation status was classified by the frequency of bowel openings (<1, 1–4, and >5 times per day). Manometric assessment was performed by an open-tip hydraulic capillary infusion system. The presence of the rectoanal relaxation reflex was determined, and the resting sphincteric pressure and resting rectal pressure were measured. Results: Seven of nine LAR patients had an acceptable frequency of one to four bowel openings per day, in contrast to 7 of 13 PSARP patients. The difference in the presentation of daily stooling is not significant (p > 0.05). A positive RAR was detected in 88.9% (8/9) of the LAR patients, and in only 30.8% (4/13) of the PSARP patients (p < 0.01). The presence of a rectoanal relaxation reflex also significantly correlated with an acceptable frequency of bowel opening (1–4 times per day) in both LAR and PSARP patients (p < 0.05). Moreover, a rectoanal relaxation reflex was detected significantly earlier in LAR than in PSARP patients (4.9 ± 1.2 vs 10.1 ± 2.5 months; postoperatively p < 0.0001). Both the LAR and PSARP patients had a similar resting sphincteric pressure (21.5 ± 4.7 vs 25.4 ± 6.2 cm H₂O; p > 0.05). By contrast, the resting rectal pressure was significantly lower in LAR than in PSARP patients (7.7 ± 1.5 vs 11.5 ± 1.3 cmH₂O; p < 0.05). Conclusions: In the early postoperative stage, patients repaired with LAR had more favorable findings in anorectal manometry than patients repaired with PSARP. Long-term follow-up studies to confirm a superior defecation continence achieved with LAR are warranted.     

Posterior cloaca—further experience and guidelines for the treatment of an unusual anorectal malformation

Introduction

The term posterior cloaca refers to a malformation in which the urethra and vagina are fused, forming a urogenital sinus that deviates posteriorly to open in the anterior rectal wall or immediately anterior to the anus.

Methods

A retrospective review of 411 patients diagnosed with cloaca was performed to identify the ones with a posterior cloaca. Special emphasis was placed on anatomy, diagnosis, associated anomalies, and outcome in terms of urinary and fecal continence. Surgical treatment was a total urogenital mobilization with a transrectal approach.

Results

Twenty-nine patients were diagnosed with a posterior cloaca. Of these, 15 had a single orifice at the normal location of the anus with the urogenital sinus opening in the anterior rectal wall. Fourteen had the urogenital sinus opening immediately anterior to the normally located anal opening (2 orifices), which we considered a posterior cloaca variant. Nineteen patients (65%) had hydrocolpos. Twenty-seven patients (93%) had associated urologic anomalies, 12 patients (41%) had gynecologic anomalies, and vertebral malformations occurred in 41% of cases. Other anomalies included gastrointestinal (7 patients), cardiac (5), and tethered cord (2). Late diagnosis occurred in 2 patients. Twenty patients were available for long-term follow-up: 17 are fecally continent, 3 are fecally incontinent, 11 are urinary continent, 5 are dry with intermittent catheterization, and 4 have dribble urine.

Conclusion

The most important characteristic of the posterior cloaca is the high frequency of a normal anus, which differentiates this malformation from the classic cloaca. Often, many associated malformations are present and therefore should be suspected and diagnosed. The main goal during the operation should be to not mobilize the anus and thereby preserve the anal canal. A total urogenital mobilization, transperineally or with a transanorectal approach, is ideal for the repair.     

Tracheoesophageal fistula after primary repair of type C esophageal atresia in the neonatal period: recurrent or missed second congenital fistula

Purpose

The aim of the study is to investigate whether a tracheoesophageal fistula (TEF) found after the primary repair of type C esophageal atresia (EA) is a recannulation of the original fistula, a missed proximal fistula, or other rare foregut malformation.

Methods

Between 2000 and 2009, 143 different types of patients with EA were admitted in our hospital. Seven patients (2 from our series, 5 referred to us by other hospitals with the history of primary repair of type C EA) had late presenting TEF. Esophagogram, 3-dimensional computed tomographic (CT) reconstruction, bronchoscopy, and reoperation were performed to confirm the TEF. Their medical records were reviewed and summarized.

Results

Persistent feeding or respiratory problems were the common symptom. The mean age of the first appearance was 17 ± 26 (1-63) months. Preoperative diagnosis was made by esophagograms and bronchoscopy in 6 patients. Reoperations were performed in all patients through thoracotomy. Missed proximal TEF shown as a distinct fistula above the primary anastomosis without much adhesion was confirmed in 5 cases. A recurrent TEF was found in 1 case. A case of communicating bronchopulmonary foregut malformation was confirmed by 3-dimensional CT reconstruction and reoperation.

Conclusion

A missed proximal TEF after repair of EA may be misdiagnosed as a recurrent TEF. Accurate preoperative diagnosis depends on combined evaluations of radiologic contrast study, 3-dimensional CT, and bronchoscopy.     

Urethral length in female infants and its relevance in the repair of cloaca

Aim of the Study

The goals of urinary reconstruction in urogenital sinus and cloacal repair include: (1) positioning of the bladder neck above the urogenital diaphragm to maximize future urinary continence, and (2) creating a visible urethra that can be catheterized if needed. A recent algorithm in cloacal reconstruction proposed a urethral length of 1.5?cm as the key determinant in deciding whether to perform a total urogenital mobilization or a urogenital separation, the hypothesis being that a 1.5?cm length urethra is needed for the patient to remain dry. We wondered if the normal female urethral length correlated with this empiric technical determinant.

The Gonzalez hernia revisited: Use of the ischiorectal fat pad to aid in the repair of rectovaginal and rectourethral fistulae

Introduction

During the development of the posterior sagittal approach to anorectal malformations a vital technical challenge was a precise midline dissection, which if off, allowed for the ischiorectal fat pad to bulge into the wound. This occurrence became affectionately known as a “Gonzalez hernia”, after a trainee of Dr Pena’s (and a co-author of this paper). We describe here an innovative use of the ischiorectal fat pad to aid in the repair of acquired rectovaginal and rectourethral fistulae.

Methods

Patients with recurrent vaginal or urethral fistulae were selected for review. The ischiorectal fat pad was deliberately mobilized (via a posterior sagittal or transanal approach) and used to buttress the repair of the posterior vagina or urethra.

Results

The ischiorectal fat pad technique was used in 9 patients. All had an acquired fistula (6 rectovaginal fistula, 3 rectourethral fistulas). We used the posterior sagittal approach in 7 and in 2 the transanal approach. Six patients had had at least two prior attempts at fistula repair. Six patients had a stoma, and 3 did not. There were no recurrences in greater than six month follow-up.

Discussion

The ischiorectal fat pad is easily visualized and mobilized, either via a posterior sagittal or transanal approach, providing excellent coverage with native, well-vascularized tissue, in an area that is difficult to heal. It is an excellent option for recurrent rectovaginal and rectovaginal fistulae and may have other additional creative applications.     

Psychosocial liaison-consultation for the children who have undergone repair of imperforate anus and Hirschsprung disease

Objective

The aim of this study was to investigate the psychological status of Japanese children with congenital anorectal malformation and their mothers to develop appropriate psychiatric interventions.

Method

The subjects comprised 50 children with congenital anorectal malformation aged 0 to 16 years and their mothers. The psychology of children aged 7 to 16 years was investigated by Kovacs' Children's Depression Inventory (CDI). The psychology of their mothers was assessed by Spielberger's State-Trait Anxiety Index (STAI) and Zung's Self-rating Depression Scale (SDS).

Results

Depression was more marked in the children aged 12 to 16 years than in those aged 7 to 11 years according to the CDI. The mothers of preschool children showed higher levels of anxiety and depression than those of school-aged children, according to the STAI and SDS. Significant correlations between the CDI score of the children and the STAI or SDS score of the mothers were observed only among children aged 7 to 11 years.

Conclusions

The frequency of depression and anxiety among children with congenital anorectal malformation and that among their mothers was associated with the age of the child. Long-term postoperative psychosocial support for the children and their mothers may be required, taking into account the age of the child.     

Can blood flow surveillance and pre-emptive repair of subclinical stenosis prolong the useful life of arteriovenous fistulae? A randomized controlled study.

BACKGROUND: Stenosis is the main cause of arteriovenous fistula (AVF) failure. It is unclear, however, if surveillance for stenosis enhances AVF function and longevity and if there is an ideal time for intervention. METHODS: In a 5-year randomized, controlled, open trial we compared blood flow surveillance and pre-emptive repair of subclinical stenoses (one or both of angioplasty and open surgery) with standard monitoring and intervention based upon clinical criteria alone to determine if the former prolonged the longevity of mature forearm AVFs. Surveillance with blood pump flow (Qb) monitoring during dialysis sessions and quarterly shunt blood flow (Qa) or recirculation measurements identified 79 AVFs with angiographically proven, significant (>50%) stenosis. The AVFs were randomized to either a control group (intervention done in response to a decline in the delivered dialysis dose or thrombosis; n = 36) or to a pre-emptive treatment group (n = 43). To evaluate a possible relationship between outcome and haemodynamic status of the access, AVFs were divided into functional and failing subgroups, according to Qa values higher or lower than 350 ml/min or the absence or presence of recirculation. RESULTS: A Kaplan-Meier analysis showed that pre-emptive treatment reduced failure rate (P = 0.003) and the Cox hazards model identified treatment (P = 0.009) and higher baseline Qa (P = 0.001) as the only variables associated with favourable outcome. Primary patency rates were higher in treatment than in control AVFs in both functional (P = 0.021) and failing subgroups (P = 0.005). They were also higher in functional than in failing AVFs in both control (P<0.001) and treatment groups (P = 0.023). Access survival was significantly higher in pre-emptively treated than in control AVFs (P = 0.050), a higher post-intervention Qa being the only variable associated with improved access longevity (P = 0.044). Secondary patency rates were similar in pre-emptively treated and control AVFs in both functional (P = 0.059) and failing subgroups (P = 0.394). They were also similar in functional and failing AVFs in controls (P = 0.082), but were higher in pre-emptively treated functional AVFs than in pre-emptively treated failing AVFs (P = 0.033) or in the entire control group (P = 0.019). CONCLUSIONS: We provide evidence that active blood flow surveillance and pre-emptive repair of subclinical stenosis reduce the thrombosis rate and prolong the functional life of mature forearm AVFs. We also show that Qa is a crucial indicator of access patency and a Qa >350 ml/min portends a superior outcome with pre-emptive action in AVFs.