Outcomes of Treatment of Anorectal Malformations: A 7-year Review at Queen Sirikit National Institute of Child Health
Keywords:
Anorectal malformations, Wingspread classification, Krickenbeck classification, long-term outcomesAbstract
Background: Anorectal malformations (ARM) are uncommon conditions and have the incidence of 1 in 4,000 to 5,000 live births. Many classifications and various operative procedures have been advocated and continuous improvement of postoperative outcome was reported.
Objective: The aim of this study was to review our experience in management of patients with ARM including classification, associated anomalies, surgical corrections and outcomes after definitive treatment.
Materials and Methods: A retrospective study was conducted by reviewing of medical records of the patients with ARM treated at Queen Sirikit National Institute of Child Health between 2006 and 2012. Patients’ data were collected including demographics, types of ARM, associated anomalies, operative procedures and results of treatment. Wingspread classification was used to categorize types of ARM and Krickenbeck classification was used to evaluate postoperative results.
Results: A total of 365 patients (220 males and 145 females) were treated for ARM during the study period. The incidence of ARM at Rajavithi Hospital was 1: 2,820 live births. Over 70% of the patients were term babies with their birth weights over 2,500 g. The levels of ARM were categorized in low, intermediate and high types in 115 (52.3%), 75 (34.1%) and 30 (13.6%) for males and 74 (51.0%), 58 (40.0%) and 4 (2.8%) for females. Persistent cloaca was noted in 9 female patients (6.2%). Most of the patients with low anomalies were treated by cutback anoplasty. Alternative surgical treatment for low anomalies in 31 females were anoplasty by anal transfer and anterior sagittal anorectoplasty (ASARP) without preliminary colostomy. The most common operative procedures for intermediate anomalies were posterior sagittal anorectoplasty (PSARP) and ASARP. For high anomalies, PSARP and abdominoperineal pull-through operation (APP) were the definitive procedures. Laparoscopic assisted anorectoplasty (LAARP) was performed in seven males with intermediate and high anomalies and two cases in female with high anomalies. Nine cases with persistent cloaca underwent posterior sagittal anorecto - urethro - vaginoplasty and seven cases survived. The most common associated anomalies were genitourinary and cardiovascular abnormalities.Twenty-six patients (7.1%) with ARM died in immediate postoperative period due to congenital heart diseases, sepsis, respiratory and neurological problems. Long-term outcomes were evaluated in 335 patients with normal fecal continence between 51.7% and 71.8%, fecal soiling or incontinence between 2.8% and 22.2%, and constipation between 24.3% and 42.9%. Patients with low and intermediate anomalies had fecal continence approximately 70% and had long-term postoperative results better than the patients with high anomalies.
Conclusion: Approximately 70% of low and intermediate types of ARM had normal fecal continence and low incidence of fecal soiling. Every type of ARM was affected with constipation in a long-term period and required dietary, medical and toilet training therapies.
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