Two-stage repair of low anorectal malformations in girls: is it truly a setback?

Abstract

Background/purpose Anorectal malformations (ARMs) affect 1 in 4000–5000 births. Low ARMs are nowadays treated in the first stage rather than at second or third stages. However, reports suggest problems with continence in these children because of wound dehiscence and infection; thus, protective colostomy may still be recommended. Colostomies do have complications, but the question is whether these disadvantages outweigh the protective effect on wound healing after anal reconstruction. The aim of this study was to define whether two-stage repair of low ARMs in girls is truly a setback or whether it is beneficial.
Patients and methods During the period of June 2008–June 2012, 30 female patients suffering from low ARMs were admitted to Mansoura University Children Hospital. Their ages at the time of surgery ranged from 3 to 11 months (mean age 6.2) and they were divided into two equal groups. The fistula location was defined either anocutaneous or anovestibular according to the Pena classification. The choice of management was totally randomized; thus, patients of group A underwent a two-stage posterior sagittal anorectoplasty and group B patients underwent a one-stage posterior sagittal anorectoplasty operation. Data recorded included age, fistula location, associated anomalies, operation performed, operative time, length of hospital stay, approximate cost, and postoperative complications.
Results A comparison of data showed that treatment of patients of group A involved more time and money and they had a longer duration of hospital stay than did patients of group B. Seven patients (47%) in group A and nine patients (60%) in group B showed postoperative complications. Wound infection occurred in three patients (20%) of group A and in eight patients (53%) of group B. More importantly, two (13%) wound disruptions occurred among the three cases with wound infection in group A, whereas six (40%) disruptions occurred among the eight patients (53%) with wound infections in group B. The incidence of redo operation in group B was found to be significantly higher than in group A. Mucosal prolapse occurred in only one patient (7%) of group B. Complications related to colostomy occurred in group A only; five patients (33%) suffered skin excoriation around the stoma and one patient (7%) showed a prolapsed distal stoma loop. Constipation was noted during follow-up in five patients (33%) of group A and in six patients (40%) of group B.
Conclusion Two-stage repair of low ARM in girls is truly beneficial, as we could perform a successful operation and achieve continence in the child regardless of the complications of colostomy, which are temporary and tolerable.

Keywords: anorectal malformations, colostomy, posterior sagittal anorectoplasty, two-stage repair of low anorectal malformation