Laparoscopically assisted anorectal pull-through for high imperforate anus in infants: intermediate results

Purpose

The aim of this study was to evaluate the clinical outcomes and postoperative anal function in infants with congenital high imperforate anus treated with laparoscopically assisted anorectal pull-through (LAARP).

Methods

From January 2004 to July 2007, 33 patients (28 boys and 5 girls, age ranging from 3 to 10 months) with high imperforate anus underwent LAARP. Clinical data of the LAARP group were retrospectively compared with those treated by posterior sagittal anorectoplasty (PSARP; n = 28) during the same time period. Anorectal function of these patients was evaluated using the following 3 methods: the Kelly score, anorectal vector volume manometry, and magnetic resonance imaging between the ages of 3.1 and 4.4 years.

Results

The mean operative time in LAARP and PSARP groups was 112.5 ± 12.4 and 120.4 ± 18.5 minutes (P > .05), respectively. The mean length of hospital stay in the LAARP group was shorter than that of PSARP group (11.3 ± 2.1 vs 14.6 ± 2.3 days, P < .01). No significant difference was observed between LAARP and PSARP groups regarding the Kelly score (3.52 ± 1.42 vs 3.49 ± 0.82). Although magnetic resonance imaging revealed lower malposition rates of rectum in the LAARP group than those of the PSARP group at both I-line (3.0% vs 14.3%) and M-line (3.0% vs 10.7%) levels, this was not statistically different (P > .05). Compared with the PSARP group, lower asymmetric index, larger vector volume, and higher anal canal pressure at rest and during voluntary squeeze were observed in LAARP group (P < .05). However, there were no significant differences in the length of high-pressure zone (15.2 ± 5.8 vs 15.1 ± 6.2 mm) and the presence of rectoanal relaxation reflex (84.8% vs 85.7%).

Conclusions

Satisfactory fecal continence can be achieved in patients with high-type imperforate anus after LAARP. Laparoscopically assisted anorectal pull-through has advantages over PSARP, including shorter hospital stay and better position of rectum. However, long-term follow-up is necessary to compare the benefits of LAARP against PSARP.     

Midterm follow-up study of high-type imperforate anus after laparoscopically assisted anorectoplasty

Purpose

The aim of this study was to evaluate postoperative anal function of high-type imperforate anus after laparoscopically assisted anorectoplasty (LAARP).

Methods

Between 2000 and 2002, LAARP was performed in 13 patients with high-type imperforate anus. Clinical data of the LAARP group were compared with the posterior sagittal anorectoplasty (PSARP) group (n = 7) operated before 2000. All patients were treated with initial colostomy in the newborn period. After anorectoplasty, daily glycerin enemas were given for postoperative bowel management. Anorectal function of these patients was evaluated using the Kelly score and manometry at the age of 3 to 5 years (LAARP) and 5 to 6 years (PSARP).

Results

Age at evaluation in the LAARP group was younger than that in the PSARP group (51 ± 10 vs 73 ± 12 months, P < .01). Kelly score was 3.8 ± 1.3 vs 3.4 ± 0.8, respectively. Resting pressure of internal sphincter was 31 ± 11 vs 33 ± 10 cm H₂O, respectively. Relaxation reflex of the internal anal sphincter was observed in 62% (8/13) and 29% (2/7), respectively.

Conclusions

Midterm follow-up study revealed that satisfactory fecal continence can be achieved in patients with high-type imperforate anus after LAARP. Laparoscopically assisted anorectoplasty may be a good alternative in this patient population. However, long-term follow-up is necessary to compare the benefits of LAARP against PSARP.     

Long term outcomes of laparoscopic-assisted anorectoplasty: A comparison study with posterior sagittal anorectoplasty

Purpose

The aim of this study is to compare the long term outcomes between laparoscopic-assisted anorectoplasty (LAARP) and posterior sagittal anorectoplasty (PSARP) for children with rectobladderneck and rectoprostatic fistula anorectal malformations (ARM).

Methods

Thirty-two ARM children with rectobladderneck and rectoprostatic fistula who underwent LAARP between October 2001 and March 2012 were reviewed. The outcomes were compared with those of 34 ARM children who underwent PSARP between August 1992 and September 2001. The sacral ratio (SR), age at operation, operative time, postoperative hospital stay and complications were evaluated. Bowel functions were assessed using the Krickenbeck classification.

Results

The mean operative time of the LAARP was significantly shorter than that of PSARP group (1.62 ± 0.40 vs 2.13 ± 0.30 h). The postoperative hospital stay was significantly shorter in the LAARP group (5.8 ± 0.65 vs 8.4 ± 0.67 h). The wound infections (11.8% vs 0%) and recurrent fistula (11.8% vs 0%) were more common in PSARP patients. The overall morbidity rate of PSARP group was significantly higher than that of the LAARP group (35.3% vs 12.5%, p < 0.05). However, 7.5% of the LAARP patients developed rectal prolapse. Twenty-four of 32 patients were followed up for more than 3 years in LAARP group. The median follow up period was 7.5 years (range 4–11) in LAARP patients and 15.5 years (range 11–20) in PSARP patients. The rates of voluntary bowel movement, soiling (grade 1, 2 & 3) were similar in both groups. More patients from PSARP group developed grade 2 or 3 constipation (22.5% vs 0%, P < 0.01).

Conclusions

Compared to PSARP, LAARP is a less invasive procedure. The long term functional outcomes after LAARP were equivalent if not better than those of PSARP.     

Use of anorectal manometry for evaluation of postoperative results of patients with anorectal malformation: a study from Kuwait

Purpose

The objective of this study is to use anorectal manometry for functional assessment of early postoperative results after corrective surgery for anorectal malformations (ARMs) in children and compare manometric observations with age-matched controls. Parents were counseled and management strategies were planned according to the manometric assessments.

Methods

From August 2005 to September 2009, 32 patients who underwent surgery for ARM were assessed postoperatively with anorectal manometry using a water-perfused anorectal motility catheter to record anal canal length or high-pressure zone, resting pressure of anal canal (RP), and rectoanal inhibitory reflex (RAIR). These patients were divided in 2 groups (infants, <1 year; children, >1 year) according to the age at the time of performance of anorectal manometry that was done at 6 months or later following stoma closure or anoplasty.

Results

Out of these 32 patients, high anomaly was present in 13, whereas 19 had low type of defect. Manometric anal canal length of the children with high and low ARM was 2.10 ± .44 and 2.25 ± .53 cm, respectively, which was significantly shorter than that of their age-matched controls(P < .05). In patients with high ARM, RP in infants (17 ± 7.7 mm of Hg) and children (21 ± 9.4 mm of Hg) was lower than that of controls (RP in infants = 42.43 ± 8.19 mm of Hg, RP in children = 43.43 ± 8.79 mm of Hg, P < .001). In patients with low ARM, RP in infants (34 ± 8.6 mm of Hg, P = .002) and children (26 ± 9.9 mm of Hg, P = .001) was lower than that in controls. Presence of RAIR was demonstrated in 5 (38.4%) of 13 patients with high ARM and in 11 (57.9%) of 19 cases with low ARM. Parental counseling was done after this early evaluation, and management strategies like bowel management program and biofeedback training were planned according to the results of the tests.

Conclusion

Our anorectal manometric results suggest that patients with ARM had short anal canal with lower RP and impaired RAIR, which could affect the ultimate functional outcome in these patients. Thus, postoperative anorectal manometric evaluation of the patients with ARM can give more realistic information about future continence and might help in planning future treatment strategies like bowel management program or biofeedback training.     

Laparoscopic-assisted anorectal pull-through for anorectal malformations: a systematic review and the need for standardization of outcome reporting

Introduction

Laparoscopic-assisted anorectal pull-through (LAARP) is becoming an increasingly common procedure to correct high and intermediate anorectal malformations (ARMs). The aim of this review was to evaluate worldwide experiences with LAARP with regard to indications, outcomes, and quality of reporting.

Method

A systematic review was conducted. The search was limited to studies reported in English and performed in humans. In addition to Medline and PubMed, a manual search of the Journal of Pediatric Surgery, Pediatric Surgery International, Surgical Endoscopy, and the Journal of Laparoendoscopic & Advanced Surgical Techniques published between June 2000 and April 2008 was conducted.

Results

Seventeen studies were included in the final analysis. Of the included studies, none were randomized, 2 were prospective in nature, and 4 compared outcomes of posterior sagittal anorectoplasty and LAARP. The studies included 124 patients (96 males, 28 females) with 80% reported as having high/intermediate malformations. All studies reported short-term outcomes. Reported outcomes included continence, rectal prolapse, the position of the rectum (7 studies using Kelly score), manometry (1 study), contrast enema (1 study), postanal endosonography (3 studies), and postoperative magnetic resonance imaging (3 studies). Outcomes varied widely between reports precluding a meta-analysis.

Conclusion

The number of studies dealing with LAARP is low. There is a need for both a standardization and improvement in the quality of reporting in LAARP research. This will ultimately allow for evidence-based surgical decision making.     

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.     

Rectal prolapse following posterior sagittal anorectoplasty for anorectal malformations

Purpose

Rectal prolapse is a known postoperative problem in children with anorectal malformations. The aims of this study were to determine the incidence of significant rectal prolapse (>5 mm), to objectively quantify its predisposing factors, and to offer recommendations as to its prevention and surgical treatment.

Methods

The authors reviewed their series of 1619 patients with anorectal malformations; 1169 underwent primary posterior sagittal anorectoplasty (PSARP) at their institution between 1980 and 2002, and complete records were available for 833. The series was analyzed for incidence of prolapse, type of anorectal malformation, status of the sacrum, muscle quality, associated vertebral and spinal anomalies, and postoperative constipation. A specific technique for prolapse repair was used.

Results

Of 833 patients, 45 developed significant rectal prolapse (3.8%). The mean age at the time of PSARP was 0.73 years (range, 0.19-5 years). The average time to recognition of prolapse following PSARP was 13.1 months. Of these 45 patients, 32 required surgical repair and of those, 3 required a second surgical repair. The incidence of prolapse varied by complexity of anorectal defect: cloaca (6.2%), rectobladder neck fistula (6.8%), rectourethral fistula (5.4%), rectovestibular fistula (1.2%), rectal atresia (0%), and rectoperineal fistula (0%). There was a significantly increased incidence of prolapse in patients with a low muscle quality score and in patients with vertebral anomalies (20% vs 3.2%). The presence of a tethered cord and an abnormal sacral ratio did not correlate with an increased incidence of prolapse. Twenty-two patients developed prolapse following colostomy closure, and of these, 12 (55%) suffered from constipation.

Conclusions

The overall incidence of significant rectal prolapse following PSARP is low. Prevention of prolapse with the PSARP technique may be because of key technical steps. Patients with higher anorectal malformations, poorer muscle quality, and vertebral anomalies had a greater risk of developing postoperative rectal prolapse. The presence of tethered cord and quality of the sacrum were not predictive of postoperative prolapse. Constipation seems to be a factor in the development of prolapse.     

Follow-up studies of anorectal malformations after posterior sagittal anorectoplasty

Background/Purpose: There are few follow-up studies comparing posterior sagittal anorectoplasty (PSARP) with conventional procedures for patients with anorectal malformations (ARM). The authors have examined retrospectively postoperative anorectal function of patients with ARM treated with PSARP compared with those treated with conventional methods. Methods: Anorectal function in 23 patients with high and intermediate type anorectal malformations (PSARP group), who underwent PSARP more than 4 years previously, were assessed by Kelly's clinical scoring system and objective studies. These results were compared with those in 14 cases (5 high and 9 intermediate type cases; control group), who underwent other conventional surgical procedures. Results: Using Kelly's clinical scoring system, scores of the PSARP group compared with the control group were good in 48% versus 21%, fair in 48% versus 58%, and poor in 4% versus 21%, respectively. Barium enema studies suggested better anorectal sphincteric function in patients with high anorectal malformation in the PSARP group. Magnetic resonance imaging (MRI) studies showed more correct placement of the rectum through the striated muscle complex in the PSARP group at the I-line level. Manometric studies showed no difference in maximum resting pressure, anal canal length, and the incidence of anorectal reflex between the two groups. Conclusions: The favorable results of MRI and barium enema studies can be explained by direct visualization of the striated muscle complex with the aid of electrical stimulation as well as no harmful effects of amputation of the sphincter muscle in PSARP. However, manometric studies suggest anorectal function in patients with high and intermediate anorectal malformations is limited even after PSARP. Long-term postoperative follow-up with adequate bowel management is required for all patients with high or intermediate anorectal malformation.     

Megarectum after surgery for anorectal malformations

Purpose

Megarectum complicating surgery for anorectal malformation (ARM) has implications for long-term continence. Factors influencing continence and defecation include intact rectal reservoir, innervation/proprioception of the anorectal muscle complex, functioning anorectal inhibitory reflex (AIR), and intact perception at the anal margin. We studied outcomes after surgery for ARM with emphasis on megarectum; particularly as to whether altered rectal proprioception from anatomic sacrococcygeal anomalies affect incidence. We also assessed whether an abnormal AIR could trigger passive rectal dilatation without mechanical obstruction.

Methods

Eighty six infants (53 male) with ARM over 20 years were included. Demographics, surgical history, pathology, defecation patterns, imaging, manometry, and morbidity were analyzed. Incidence of sacrococcygeal malformations in children with and without megarectum was compared using Fisher exact test. Manometry results were evaluated for integrity of AIR and correlated to megarectum occurrence.

Results

There were 23 high/intermediate and 63 low ARMs. Fourteen (16%) developed a megarectum: 6 of 23 in high and 8 of 63 in low anomalies (P = .33). Twelve patients underwent megarectum resection at a median of 2.6 years (7 months to 10 years); 2 received bowel management protocols. Fifty-seven percent (8/14) of children with and 7% (5/72) without megarectum had sacrovertebral anomalies (P = .0001). Patients with preoperative manometry (n = 5) demonstrated an intact AIR. Colonic manometry demonstrated hyperactive colons (n = 2). Constipation was the predominant preoperative symptom; 3 patients suffered from incontinence after resection. All the specimens showed normal innervation and thickened muscularis on pathology.

Conclusions

Sacral anomalies, which are more prevalent in children who developed megarectum, may result in abnormal rectal proprioception contributing to this pathology. Innervation anomalies may coexist, although preoperative manometries showed normal AIRs. Rectal dysmotility may lead to stool retention with subsequent dilatation, and patients who underwent colonic manometry had diffuse colonic hypermotility. Further physiologic and cellular studies are needed to elucidate the causes of this significant complication after surgical ARM repair in the absence of obstruction.     

Quantitative analysis of sacral parasympathetic nucleus innervating the rectum in rats with anorectal malformation

Background/Purpose

The purpose of this experiment was to identify the neurons in the lumbosacral spinal cord involved in colon-rectal function and to compare normal and anorectal malformation of fetalrats.

Methods

The authors quantified the sacral parasympathetic nucleus (SPN) innervation of the rectum by Fluorogold (FG) (Fluorochrome, Englewood, CO) retrograde tracing experiment in fetal rats with normal and anorectal malformation. Anorectal malformation was induced in rat fetuses by ethylenethiourea (ETU). The number of FG-labeled SPNs was scored and compared between male fetuses with or without malformation in the ETU-fed group and control groups.

Results

The number of FG-labeled SPNs in the fetuses without a defect, with ETU injected but without any defects of the anorectum or neural tube, with low-type deformity, and with high-type deformity were (mean ± SEM) 47.3 ± 2.9, 45.6 ± 3.2, 24.2 ± 3.8, and 8.5 ± 2.5, respectively. Fluorogold-labeled SPNs inthe fetuses with high-type deformity were significantly fewer than those in fetuses without defects (P<.05) and in controls (P < .05).

Conclusions

These findings suggest that defective SPN innervation to the rectum is a primary anomaly that coexists with the alimentary tract anomaly in anorectal malformation during fetal development. The intrinsic neural deficiency is an important factor likely to contribute to poor postoperative anorectal function despite surgical correction of the malformation.     

Anorectal malformations with good prognosis: Variables affecting the functional outcome

Backgroud/Purpose

The purpose of this study was to investigate the outcome of patients operated for anorectal malformations (ARMs) with good prognosis.

Methods

Thirty patients underwent clinical evaluation by Rintala score and anorectal manometry recording anal resting pressure (ARP), rectoanal inhibitory reflex (RAIR), and rectal volume (RV). The results were analysed with regard to sex, type of ARM, surgical timing of posterior sagittal anorectoplasty (PSARP), neurospinal cord dysraphism (ND), neonatal colostomy, and institution where they underwent surgery.

Results

6/30 (20%) presented ND despite normal sacrum. 17/30 (57%) patients had a normal Rintala score. ND and neonatal colostomy were significantly associated with a pathologic score (p = 0.0029 and p = 0.0016). Patients with ND had significantly lower ARP compared to patients with normal spine (23.5 ± 7.2 mmHg vs 32 ± 7.9 mmHg, p = 0.023). ARP was significantly lower in patients with neonatal colostomy compared to patients with primary repair (25.22 ± 10.24 mmHg vs 32.57 ± 6.68 mmHg, p = 0.026). RAIR was present in only 2/6 (33%) patients with ND, while in 21/24 (87.5%) without ND (p = 0.015) and in 4/9 (44%) patients with neonatal colostomy, while in 19/21 (90.5%) patients submitted to primary repair (p = 0.014).

Conclusions

Neurospinal cord dysraphism may be present despite normal sacral ratio. From a clinical point of view, patients with good prognosis ARMs are not completely comparable to healthy children. Neurospinal cord dysraphism and neonatal colostomy seem to worsen the clinical and manometric (ARP and RAIR) outcomes of these patients.     

Robotic-assisted anorectal pull-through for anorectal malformations

Background/purpose

Many reports have addressed the feasibility and safety of using robotic surgery in children. To our knowledge, no published report has described the use of a surgical robot in the repair of anorectal malformations (ARMs).

Methods

Included children underwent robotic-assisted repair of ARMs with rectourethral fistula between April 2006 and March 2010 at King Khalid University Hospital, Riyadh, Saudi Arabia, using the da Vinci Surgical System. Their medical records were reviewed with respect to demographic data, associated anomalies, techniques and operative procedures, complications, outcomes, and follow-up.

Results

Five male infants (mean age, 6.6 months) underwent robotic-assisted repair of ARMs with rectourethral fistula using the Georgeson technique. The fistulae were divided and ligated in 4 patients and was left open in 1. All procedures were successfully completed without conversion to an open technique. One patient developed left-sided epididymo-orchitis postoperatively. All the patients had their colostomy closed. The follow-up ranged from 6 to 36 months. Fecal continence was difficult to assess in 2 patients. Two patients have voluntary bowel movements without soiling. One infant has fecal soiling and is on a laxative/enema for constipation.

Conclusions

Robotically assisted repair of ARMs with rectourethral fistula is feasible and safe. It offers a good alternative to the criterion standard, posterior sagittal anorectoplasty (PSARP), for repair of ARMs with rectourethral fistula. More patients and a longer follow-up period are needed for further evaluation of this novel approach.     

Comparison of anorectal angle and continence after Georgeson and Peña procedures for high/intermediate imperforate anus

Aim

The anorectal angle (AA) influences defecation after pull-through (PT) for imperforate anus (IA). We compared postoperative AA and continence after Georgeson's laparoscopy-assisted colon PT (GPT) and Peña's posterior sagittal anorectoplasty (PSARP) for high/intermediate-type IA.

Methods

We reviewed 33 high/intermediate-type IA cases (20 GPTs and 13 PSARPs) prospectively. All had colostomy initially as neonates. Anorectal angle was measured as the angle between the rectum and the anal canal on barium enema. A fecal continence evaluation questionnaire (FCEQ) consisting of 5 parameters (frequency of defecation, staining/soiling, perianal erosion, anal shape, and requirement for medication; maximum score = 10) was evaluated in 28 cases (15 GPTs and 13 PSARPs) followed up for more than 3 years.

Results

Mean age at PT was similar (6.6 months for GPT and 6.3 months for PSARP; P = not significant). There was no significant difference in mean AA. The FCEQ scores for GPT were generally higher throughout the study and significantly better from 3 years postoperatively (P < .05).

Conclusions

We are the first to confirm that effective AA similar to PSARP can be achieved after GPT, although FCEQ would suggest that GPT has less detrimental functional impact.     

The treatment of high and intermediate anorectal malformations: one stage or three procedures?

Background/Purpose

The aim of this study was to examine the safety, feasibility, and the long-term outcome of complete 1-stage repair of high and intermediate anorectal malformation using posterior sagittal anorectoplasty (PSARP) in a neonate.

Methods

One hundred thirteen patients with high-type and intermediate-type anorectal malformations (ARM) underwent follow-up. Of 113 cases, 48 cases entailed a divided colostomy, definitive operation, and colostomy closure (group I); the other 65 patients underwent 1-stage PSARP (group II). Anorectal function was measured by the modified Wingspread scoring, including “excellent,” “good,” “fair,” and “poor.” In barium enema studies, anorectal angulation was judged as “clear,” “unclear,” and “not present,” and leakage of barium was observed in the meantime. For anorectal manometric studies, anal resting pressure (ARP), anal squeezing pressure (ASP), and positive anorectal reflex (PAR) were measured.

Results

In group I, the rate of excellent and good scores was 58.3% (28 of 48). In the barium enema examination, 85.4% (41 of 48) was clear and 14.6%(7 of 48) unclear or not present. The rate of barium leakage was 10.4% (5 of 48). In group II, the rate of excellent and good was 53.8% (35 of 65). Anorectal angulations were clear in 83.1% of patients (54 of 65). Barium leakage happened in 7.69% of patients (5 of 65). Early operative complications occurred in 56.3% (27 of 48) of patients in group I and 29.2% (19 of 65) in group II. The incidence of colostomy complications in group I was 39.6% (19 of 48). Soiling and constipation were the major complications after the PSARP operation. The respective rates of constipation in the 2 groups were 47.9% (23 of 48) and 44.6% (29 of 65), and the respective rates of soiling were 47.9% (23 of 48) and 50.8% (33 of 65). There was no significant difference in the mean ARP between the 2 groups.

Conclusions

The 1-stage PSARP procedure in the neonate not only achieves the same long-term outcome as the conventional PSARP procedure but also involves fewer short-term complications. Complete 1-stage repair using the PSARP to treat high-type and intermediate-type anorectal malformations is safe and feasible.     

Laparoscopic versus open abdominoperineal rectoplasty for infants with high-type anorectal malformation

Background/Purpose

There has not been any study comparing laparoscopic abdominoperineal rectoplasty (ARP) with open ARP. This study investigated the true benefits of the laparoscopic approach in infants with high anorectal malformation.

Patients and methods

A retrospective analysis was performed in 28 infants with high anorectal malformation treated between 1990 and 2007. Fifteen were treated by open ARP, and 13 were treated by laparoscopic ARP. Surgical durations, amount of bleeding, complications, anorectal pressure measurements, barium enema study, and clinical assessment were compared between the 2 groups.

Results

The amount of intraoperative bleeding was significantly less in laparoscopic ARP (12 ± 11 g) than in open ARP (65 ± 44 g) (P = .003). Anal resting pressure was 34 ± 9 cm H₂O after laparoscopic ARP and 31 ± 14 cm H₂O after open ARP. Anorectal reflex was positive in 1 (7%) of 15 after open ARP and 3 (23%) of 13 after laparoscopic ARP. There was no significant difference in barium enema study and clinical assessment between the 2 groups. With regard to postoperative complications, mucosal prolapse occurred in 10 (67%) of 15 after open ARP and in none of 13 after laparoscopic ARP (P = .003).

Conclusion

Benefits of the laparoscopic approach were reduced intraoperative bleeding and a lower incidence of postoperative anal mucosal prolapse. These results indicate that minimal dissection of the mesorectum in laparoscopic ARP may provide those better outcomes.     

Deficient motor innervation of the sphincter mechanism in fetal rats with anorectal malformation: a quantitative study by fluorogold retrograde tracing

Background/purpose: Deficiency of motoneuron innervation to the sphincter mechanism has been described in patients with anorectal malformation. Whether this event is primary or secondary remains unclear.Methods: The authors quantified the motoneuron innervation of the sphincter mechanism by Fluorogold (FG) retrograde tracing experiment in fetal rats with anorectal malformation. Anorectal malformation was induced in rat fetuses by ethylenethiourea (ETU). Serial longitudinal sections encompassing the whole width of lumbosacral spinal cord were examined. The number of FG-labelled motoneurons were scored and compared between male fetuses with or without malformation in the ETU-fed group and normal controls.Results: The number of FG-labelled motoneurons in the fetuses without defect, with imperforate anus (IA), with neural tube anomalies (NTA), with combined IA and NTA, and normal controls were determined to be (mean ± SEM) 109.13 ± 37.88, 55.05 ± 25.85, 48.20 ± 30.34, 54.43 ± 28.55, and 135.22 ± 28.78, respectively. FG-labelled motoneurons in the fetuses with IA, NTA, and combined IA and NTA are significantly fewer than that in fetuses without defects (P < .05) and in normal controls (P < .005).Conclusions: These findings suggest that defective motoneuron innervation to the sphincter mechanism is a primary anomaly that coexists with the alimentary tract anomaly in anorectal malformation during fetal development. The intrinsic neural deficiency is an important factor likely to contribute to poor postoperative anorectal function despite surgical correction of anorectal malformation.     

Manometric tests of anorectal function in 90 healthy children: a clinical study from Kuwait

Background/Purpose

Anorectal manometry is a noninvasive test used to evaluate conditions like slow-transit constipation, anorectal outlet obstruction, and Hirschsprung disease and to assess postoperative results after Hirschsprung and anorectal malformations. This cross section study was designed to have normal manometric values of anorectal function in healthy children of different ages in Kuwait so that control values are available for comparisons with various pathological states.

Method

Anorectal manometry was conducted in 90 children aged 3 days to 12 years without any symptoms related to lower gastrointestinal tract. They were divided in 3 age groups (group 1—neonates up to 1 month, group 2—infants from 1 month to 1 year, and group 3—children more than 1 year). Water perfused system with anorectal catheter with 4 side holes was used to record length of anal canal or high-pressure zone, resting pressure of anal canal, and rectoanal inhibitory reflex (RAIR).

Result

Anorectal manometry was successfully done in all 90 children of different age groups without any complications. High-pressure zone or anal canal length was 1.67 ± 0.34 cm in neonates, 1.86 ± 0.6 cm in infants, and 3.03 ± 0.52 cm in children. Mean resting pressure of anal canal was 31.07 ± 10.9 mm Hg in neonates, 42.43 ± 8.9 mm Hg in infants, and 43.43 ± 8.79 mm Hg in children. Rectoanal inhibitory reflex was present in all of them. Mean RAIR threshold volumes of 9.67 ± 3.6, 14.0 ± 9.5, and 25.0 ± 11.6 mL was required for noenates, infants, and children, respectively.

Conclusion

Resting pressure of the anal canal, manometic anal canal length, and RAIR volume varies with the age. Normal values anorectal manometry at different age groups should be obtained to compare with pathological states of anorectum.     

Evaluation of defecative function 5 years or longer after laparoscopic-assisted pull-through for imperforate anus

Background

Laparoscopic anorectoplasty was introduced in 2000, but the procedure has not yet gained universal acceptance. Previous studies, including ours, reported satisfactory early postoperative outcome as compared with posterior sagittal anorectoplasty (PSARP), but mid- to long-term results are not available. Here, we aim to evaluate the mid- to long-term defecative function in these patients.

Materials and Methods

A retrospective study was carried out and included all patients who underwent laparoscopic-assisted anorectoplasty for high-/intermediate-type imperforate anus between 2001 and 2005. Their degree of continence was graded according to the Krickenbeck classification and compared with historical controls treated with PSARP. The results were compared using χ² test, and P < .05 was considered statistically significant.

Results

There were 18 patients who underwent laparoscopic anorectoplasty (LAR) in the study period. They were compared with 20 historical PSARP patients. For defecation sensation, 16 of the 18 LAR patients were positive, whereas there were 16 of 20 PSARP patients. Eight LAR patients were clean without any fecal soiling or incontinence (11/20 PSARP). Only 3 of 18 LAR had constipation as compared with 7 of 20 PSARP. The need for rectal enema for evacuation was seen in 1 of 20 LAR patients and 2 of 20 PSARP patients (for all categories, P > .05).

Conclusions

Mid- to long-term follow-up study revealed satisfactory defecative function for patients with high-/intermediate-type imperforate anus after LAR. The outcome is at least as good as PSARP. Longer term follow-up with larger sample size is necessary to demonstrate the benefits of LAR over PSARP.     

Neuronal immaturity in normoganglionic colon from cases of Hirschsprung disease, anorectal malformation, and idiopathic constipation

Aim

Immaturity of neurons in normoganglionic colon in Hirschsprung disease (HD), anorectal malformation (AM), idiopathic constipation (IC), and normal controls (C) was assessed using polysialyated neural cell adhesion molecule.

Methods

Polysialyated neural cell adhesion molecule immunoreactivity in 3 sections of normoganglionic colon from HD (n = 48), AM (n = 25), IC (n = 36), and C (n = 18) were scored semiquantitatively according to age; 1 day to 11 months (G1), 1 to 4 years (G2), and 5 years and older (G3).

Results

Neurons in all specimens appeared mature irrespective of age on hematoxylin-eosin stain. Polysialyated neural cell adhesion molecule was positive (immaturity) in all specimens during G1 (1.34 in HD, 1.60 in AM, 0.89 in IC, and 1.59 in C) and decreased significantly with age in C (0.34* for G2, 0.25* for G3; *P < .01), decreased after 4 years old in IC (0.93 for G2, 0.10^# for G3; ^#P < .05), decreased gradually in AM (1.10 for G2, 0.75^§ for G3; ^§P < .05), but remained strongly positive in HD (1.34 for G1, 1.26 for G2, and 1.21 for G3; P = not significant), which after 4 years was significantly higher than C (P < .05).

Conclusion

Postoperative colonic dysmotility may be because of persistence of immature neurons in HD and impaired maturation of neurons in AM and IC.