On-line version ISSN 2078-5151
S. Afr. j. surg. vol.49 n.1 Cape Town Feb. 2011
C. de VosI; M. ArnoldII; D. SidlerIII; S. W. MooreIV
IM.B. CH.B., D.M.O.; Division of Paediatric Surgery, Stellenbosch University, Tygerberg, W Cape
IIM.B. CH.B., D.CH.; Division of Paediatric Surgery, Stellenbosch University, Tygerberg, W Cape
IIIM.D. (berne), M.Phil. (applied Ethics), F.C.S. (SA)Division of Paediatric Surgery, Stellenbosch University, Tygerberg, W Cape
IVM.B. Ch.B., F.R.C.S. (ed.), M.D.Division of Paediatric Surgery, Stellenbosch University, Tygerberg, W Cape
INTRODUCTION: Laparoscopic-assisted anorectoplasty (LAARP) has gained popularity since its introduction in 2000. Further evidence is needed to compare its outcome with the gold standard of posterior sagittal anorectoplasty (PSARP).
METHOD: A retrospective review of patients presenting with anorectal malformation (ARM) in the period 2000 - 2009. Demographics, associated abnormalities, and operative and post-operative complications were assessed. The functional outcome in children older than 3 years was assessed, applying the Krickenbeck scoring system and, where possible, by interviewing parents. Patients with cloacal abnormalities were excluded. Patients with a LAARP were compared with those managed by PSARP.
RESULTS: Seventy-three patients with ARM were identified during the study period. Male to female ratio was 1.6:1. All 32 low ARMs (perineal and vestibular fistulae) were excluded. Thirty-nine had levator or supra-levator lesions. Twenty males presented with recto-bulbar, 3 with recto-prostatic, and 1 with a recto-vesical fistula; 2 had no fistula; and in 2 the data were insufficient to determine the level. Among the females, 6 had recto-vaginal fistulae, 4 had cloacas and 1 had an ARM without fistula. There were 3 syndromic ARMs (2 trisomy 21 and 1 Baller-Gerold syndrome). One neonate with a long-gap oesophageal atresia had a successful primary LAARP. Seventy-five per cent of all patients had VACTERL associations. Two early deaths after colostomy formation were related to a cardiac anomaly and an oesophageal atresia.
In both groups, mean age at anoplasty was 8 months. Twenty of the intermediate/high lesions were treated with LAARP, and 19 by PSARP.
There were slightly more complications in the LAARP group; intra-operative injury to the vas deferens and urethra occurred once each. Post-operatively, 2 port-site hernias and 1 case of pelvic sepsis occurred. A poorly sited colostomy caused difficulty in 2 patients. Two patients were converted to laparotomy: severe adhesions in one and a poorly sited stoma in another. Five patients required redo-anoplasty for mucosal prolapse, anal stenosis, incorrect placement of the anus, retraction of the rectum and an ischaemic rectal stricture. Complications in the PSARP group included 2 wound dehiscences, 1 anal stenosis, 3 mucosal prolapses, 1 recurrent fistula and 2 incorrect anal placements requiring redo surgery.
The Krickenbeck questionnaire was used in 70% of PSARPs (mean age 5.9 years) and LAARPs (mean age 5.5 years) for a functional assessment. Both groups showed voluntary bowel movements in 14%. Soiling and overflow incontinence was a significant problem. Grade III constipation was less common in the LAARP (14%) than PSARP (21%) group. Four patients in the LAARP group were reliant on regular rectal washouts compared with 6 in the PSARP group.
CONCLUSION: Both LAARP and PSARP can successfully treat ARM but have specific associated problems.
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