Surgical management of anorectal malformations based on Krickenbeck classification: 13 - year experience from a single institute
Keywords:
Anorectal malformations, Krickenbeck classification, posterior sagittal anorectoplasty, posterior sagittal anorectovaginourethroplasty, abdominoperineal pull-throughAbstract
Background: Anorectal malformations (ARMs) represent a wide spectrum of disease with various operative managements. Posterior sagittal anorectoplasty (PSARP) has been developed as the standard technique. However, there are still controversies in the management of ARMs.
Objectives: The objective of this study was to assess the operative managements including associated anomalies and functional outcome of anorectal malformations at King Chulalongkorn Memorial Hospital over a 13-years.
Methods: A retrospective study was conducted at King Chulalongkorn Memorial Hospital between January 2004 and December 2016. Patients’ information was classified based on Krickenbeck classification. Statistical analysis was performed using IBM SPSS statics 22.0 version for MAC.
Results: A total of 96 patients underwent repair of ARMs. The most common ARMs in male patients were rectourethral fistulas (32.0%) and in female patients were vestibular fistulas (45.0%). Seventy-five (78.0%) patients had at least one associated anomaly. Thirty-four patients (36.0%) had VACTERL association. There were 74 (77.0%) patients were managed with colostomy as staged procedures. All patients with rectourethral bulbar fistulas underwent PSARP (11/11) while patients with rectourethral prostatic fistulas or rectovesical fistulas underwent abdominoperineal pull-through (12/17), PSARP with laparotomy (4/17) and PSARP (1/17). ARMs with perineal fistulas underwent cut back operation (7/13), PSARP (3/13) and ASARP (3/13) depending on surgeons’ preferences. ARMs with vestibular fistulas underwent PSARP (15/21) or ASARP (6/21). Mostly cloacal malformations underwent PSARVUP with laparotomy (6/13). ARMs with no fistula underwent PSARP (13/13). H-type ARMs underwent fistulectomy (4/5) and ASARP with protective colostomy (1/5). Fifty-three patients (61.0%) had no postoperative complications. Continence was achieved in 80.0% of the patients. The median time of follow up is 4.5 years.
Conclusion: In our series, the incidences of ARMs according to Krickenbeck classification are quite similar compared to other studies. Operative managements of ARMs are highly variable depending on types of ARMs. Functional outcome is also comparable to other studies.
Downloads
References
Levitt MA, Pena A. Imperforate anus and cloacal malformations. In: Holcomb III GW, Murphy JP, editors. Ashcraft's pediatric surgery. 5th ed. Philadelphia, PA: Saunders Elsevier;2010. p. 468-90.
https://doi.org/10.1016/B978-1-4160-6127-4.00036-7
Pena A. Anorectal malformations. Semin Pediatr Surg 1995;4:35-47.
Holschneider A, Hutson J, Pena A, Beket E, Chatterjee S, Coran A, et al. Preliminary report on the International Conference for the Development of Standards for the Treatment of Anorectal Malformations. J Pediatr Surg 2005;40:1521-6. https://doi.org/10.1016/j.jpedsurg.2005.08.002
Pena A, De Vries P. Posterior sagittal anorectoplasty: important technical considerations and new applications. J Pediatr Surg 1982;17:796-811. https://doi.org/10.1016/S0022-3468(82)80448-X
De Vries P, Pena A. Posterior sagittal anorectoplasty. J Pediatr Surg 1982;17:638-43.
https://doi.org/10.1016/S0022-3468(82)80126-7
Patrapinyokul S, Sujijantararat P. Posterior sagittal anorectoplasty for imperforate anus: a preliminary result. J Med Assoc Thai 1993;76:23-8.
Pena A. Preface:advances in anorectal malformations. Semin Pediatr Surg 1997;6:165-9.
de Blaauw I, Wijers CH, Schmiedeke E, Holland-Cunz S, Gamba P, Marcelis CL, et al. First results of a European multi-center registry of patients with anorectal malformations. J Pedatr Surg 2013;48:2530-5.
https://doi.org/10.1016/j.jpedsurg.2013.07.022
Bischoff A, Frischer J, Dickie BH, Pena A. Anorectal malformation without fistula: a defect with unique characteristics. Pediatr Surg Int 2014;30:763-6. https://doi.org/10.1007/s00383-014-3527-5
Stoll C, Alembik Y, Dott B, Roth MP.Associated malformations in patients with anorectal anomalies. Eur J Med Genet 2007;50:281-90. https://doi.org/10.1016/j.ejmg.2007.04.002
Singh S, Wakhlu A, Pandey A, Singh A, Kureel SN, Rawat J, et al. Esophageal atresia associated with anorectal malformation: Is the outcome better after surgery in two stages in a limited resources scenario? J Indian Assoc Pediatr Surg 2012;17:107-10. https://doi.org/10.4103/0971-9261.98123
Nah SA, Ong CC, Lakshmi NK, Yap TL, Jacobsen AS, Low Y. Anomalies associated with anorectal malformations according to the Krickenbeck anatomic classification. J Pediatr Surg 2012;47:2273-8.
https://doi.org/10.1016/j.jpedsurg.2012.09.017
Balanescu RN, Topor L, Moga A. Anomalies associated with anorectal malformations. Chirurgia 2013;108:38-42.
Casaccia G, Catalano OA, Bagolan P. Congenital gastrointestinal anomalies in anorectal malformations: what relationship and management? Congenit Anom 2009;49:93-6.
https://doi.org/10.1111/j.1741-4520.2009.00230.x
Cho S, Moore SP, Fangman T. One hundred three consecutive patients with anorectal malformations and their associated anomalies. Arch Pediatr Adolesc Med 2001;155:587-91.
https://doi.org/10.1001/archpedi.155.5.587
Ratan SK, Rattan KN, Pandey RM, Mittal A, Magu S, Sodhi PK. Associated congenital anomalies in patients with anorectal malformations - a need for developing a uniform practical approach. J Pediatr Surg 2004;39:1706-11. https://doi.org/10.1016/j.jpedsurg.2004.07.019
Pena A, Migotto-Krieger M, Levitt MA. Colostomy in anorectal malformations: a procedure with serious but preventable complications. J Pediatr Surg 2006;41:748-56.
https://doi.org/10.1016/j.jpedsurg.2005.12.021
Whyte C, Canty TG, Smith J, Melody K. Anoplasty for low anorectal malformation. J Pediatr Surg 2016;51:1602-6. https://doi.org/10.1016/j.jpedsurg.2016.03.007
Adeniran JO. One-stage correction of imperforate anus and rectovestibular fistula in girls: Preliminary results. J Pediatr Surg 2002;37:E16. https://doi.org/10.1053/jpsu.2002.32927
Liu G, Yuan J, Geng J, Wang C, Li T. The treatment of high and intermediate anorectal malformations: one stage or three procedures? J Pediatr Surg 2004;391466-71.
Patwardhan N, Kiely EM, Drake DP, Spitz L, Pierro A. Colostomy for anorectal anomalies: high incidence of complications. J Pediatr Surg 2001;36:795-98. https://doi.org/10.1053/jpsu.2001.22963
Levitt MA, Pena A. Anorectal malformations. In: Coran AG, Adzick NS, Krummel TM, Laberge JM, Shamberger RC, Caldamone AA, editors. Pediatric surgery. Philadelphia: Saunders Elsevier; 2012. p. 1289-1309. https://doi.org/10.1016/B978-0-323-07255-7.00103-3
Karakus SC, User IR, Akcaer V, Ceylan H, Ozokutan BH. Posterior sagittal anorectoplasty in vestibular fistula: with or without colostomy. Pediatr Surg Int 2017;33:755-9. https://doi.org/10.1007/s00383-017-4102-7
Lawal TA, Chatoorgoon K, Bischoff A, Pena A, Levitt MA. Management of H-type rectovestibular and rectovaginal fistulas. J Pediatr Surg 2011;46:1226-30. https://doi.org/10.1016/j.jpedsurg.2011.03.058
Wu YM, Wang CD, Lv F, Zhang C, Yan ZL. The surgical management of H-type rectovestibular fistula: a novel modification. Eur J Pediatr Surg 2016;26:336-9. https://doi.org/10.1055/s-0035-1552569
Kelleher DC, Henderson PW, Coran A, Spigland NA. The surgical management of H-type rectovestibular fistula: a case report and brief review of the literature. Pediatr Surg Int 2012;28:653-6.
https://doi.org/10.1007/s00383-012-3064-z
Banu T, Hoque M, Laila K, Ashraf Ul H, Hanif A. Management of male H-type anorectal malformations. Pediatr Surg Int 2009;25:857-61. https://doi.org/10.1007/s00383-009-2433-8
Wang ZM, Chen YJ, Zhang TC, Peng CH, Pang WB, Zhang D, et al. Anterior perineal fistulectomy in repairing H-type rectovestibular fistula with a normal anus in female children. J Pediatr Surg 2015;50:1425-8. https://doi.org/10.1016/j.jpedsurg.2015.04.003
Jung SM, Lee SK, Seo JM. Experience with laparoscopic-assisted anorectal pull-through in 25 males with anorectal malformation and rectourethral or rectovesical fistulae: postoperative complications and functional results. J Pediatr Surg 2013; 48:591-6. https://doi.org/10.1016/j.jpedsurg.2012.08.001
Rintala RJ, Pakarinen MP. Imperforate anus; longand short-term outcome. Semin Pediatr Surg 2008;17:79-89. https://doi.org/10.1053/j.sempedsurg.2008.02.003
Pena A. Anorectal malformations. Semin Pediatr Surg 1995;4:35-47.
Rintala RJ, Lindahl H. Is normal bowel function possible after repair of intermediate and high anorectal malformations? J Pediatr Surg 1995;30:491-4. https://doi.org/10.1016/0022-3468(95)90064-0
Nam SH, Kim DY, Kim SC. Can we expect a favorable outcome after surgical treatment for an anorectal malformation? J Pediatr Surg 2016;51:421-4. https://doi.org/10.1016/j.jpedsurg.2015.08.048
Rintala RJ, Marttinen E, Virkola K, Rasanen M, Baillie C, Lindahl H. Segmental colonic motility in patients with anorectal malformations. J Pediatr Surg 1997; 32:453-6.
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2023 Chulalongkorn Medical Journal
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
