Functional Outcomes of Patients Who Underwent Anorectal Malformation Repair Using MRI Guidance.

BACKGROUND: Despite the initiation of minimally invasive laparoscopic techniques, the majority of patients who undergo anorectal malformation repair still experience functional bowel issues in childhood, including constipation and fecal incontinence. In this study, we evaluate the functional outcomes of a procedure in which magnetic resonance imaging guidance is used during initial laparoscopic repair to better locate the epicenter of the sphincter muscle complex and pelvic floor with the goal of more accurate placement of the neoanus and improved functional outcomes. METHODS: A retrospective chart review evaluated demographic, operative, and outcome details for patients who underwent this procedure. A telephone survey was employed to determine levels of social continence using the validated Baylor Continence Scale and to determine what type of bowel management is used. RESULTS: Twenty-six patients were included. Median age at operation was 7 months, and median age at follow-up was 4 years old, with a range of 1-9. Bowel management regimen results revealed that 19 % (n = 5) use no bowel management regimen, 58 % (n = 15) use laxatives only, and 23 % (n = 6) use enemas. Enema use was not associated with different spine or sacral anomalies (p = 0.77). Fifteen patients (58 %) answered the Baylor Continence Scale questions and had a median score of 14. No difference was found in scores when accounting for lesion level (p = 0.43), quality of needle placement (p = 0.46), or quality of sphincter muscles (p = 0.75). CONCLUSIONS: Using MRI guidance in the repair of anorectal malformations shows promise in both the qualitative and quantitative functional outcomes of this complex patient population. LEVEL OF EVIDENCE: Level III.

[The pathological physiology of the anorectal defects, from the new concept to the new treatment].

PURPOSE: To determine physiology of anorectal zone in norm and anorectal malformations (ARM) to optimize the surgical treatment. MATERIAL AND METHODS: Examination of 119 patients were selected, including 65 children without anorectal pathology and 54 patients with ARM. We performed barium enema with radiopaque marker placed near the anus. The manometric study of anorectal area was done using intubation tube with an inflatable cuff. RESULTS: The anal canal was detected in all of ARM patients with perineal and vestibular fistulas, as well as in most of the newborns without fistula. The well innervated internal anal sphincter (IAS) was located in the loop of the puborectal muscle (PRM) and connected to the levator ani muscle (LAM) which opens the anal canal during defecation. Anterior and posterior sagittal approaches use IAS excision, with PRM damage and cutting off the LAM from IAS, which leads to incontinence and/or chronic constipation. CONCLUSION: We describe two surgical approaches that allow preservation of all elements of the anal canal resulting in a normal post-operative continence and defecation.

Laparoscopically assisted anorectoplasty using perineal ultrasonographic guide: a preliminary report.

BACKGROUND/PURPOSE: As minimal invasive surgery, laparoscopically assisted anorectal pull-through has been reported with new devices. However, it is not easy to create an accurate pull-through canal (PTC) because of the narrow space between the urethra and puborectal sling. The authors describe a new method using perineal ultrasonography. METHODS: The rectourethral prostatic fistula was dissected laparoscopically. Externally, electrostimulation identified the center of the muscle contraction, over which a 1.2-cm skin incision was made, and the lower part of PTC was created by hemostat forceps guided by electrostimulation. An ultrasonographic probe applied to the perineum demonstrated the urethra, and the forceps was advanced behind the urethra into the pelvic cavity using the ultrasonographic guide. Anorectal pull-through was performed after dilatation of the PTC with dilators. RESULTS: The authors applied this procedure in 5 cases of male high and intermediate anomalies. Surgical damages to the urethra and the levator and vertical muscles were not encountered. Postoperative fluoroscopic study demonstrated good anterior angulation and intact contraction and relaxation of those muscles. CONCLUSION: The combination of laparoscopic dissection, pinpointing the center of anal sphincter by electrostimulation, and identification of the urethra by ultrasonographic images from the perineum facilitated creation of appropriate PTC in the muscle complex.

[Congenital colonic atresia. Surgery correction in one or two stages?]. / Atresia de sigma cierre quirúrgico primario o secundario?

Sigmoid atresia is rare, the recognzed prevalence is 1 per 15.000 to 60.000 live born. We present a 30 hours old boy with vomiting, abdominal distension and failure to pass meconium. Physical examination showed severe abdominal distension. An enema was performed and a gray mucus plug taken out. The abdominal plain XR showed bowel obstruction and in a barium enema only 5-7 cm of microcolon was seen. With the diagnosis of sigmoid atresia the patient underwent surgery, observing one atresia type I, with dilated proximal loop and distal microcolon. A colostomy was performed and few days later one end-to-end anastomosis was made.

The Currarino triad: complex of anorectal malformation, sacral bony abnormality, and presacral mass.

The Currarino triad is a unique complex of congenital caudal anomalies including anorectal malformation, sacral bony abnormality, and presacral mass. The usual symptomatology is constipation due to anorectal stenosis. Contrast enema and computed tomographic myelography are the imaging modalities of choice for diagnostic confirmation and clarification of the anomalies. The clinical features, unique radiologic appearance, and importance of a correct diagnosis of the Currarino triad are reviewed.