Application of anchoring stitch prevents rectal prolapse in laparoscopic assisted anorectal pullthrough

doi:10.1016/j.jpedsurg.2016.09.051

Journal of Pediatric Surgery

Volume 51, Issue 12, December 2016, Pages 2113-2116

https://doi.org/10.1016/j.jpedsurg.2016.09.051 Get rights and content

Abstract

Background

Rectal prolapse has been reported after laparoscopic assisted anorectal pullthrough in children with anorectal malformation. We report our clinical outcome and study the application of an anchoring stitch to tack the rectum to the presacral fascia and the occurrence of rectal prolapse.

Material and methods

A retrospective review of all children who had undergone laparoscopic assisted anorectal pullthrough for anorectal malformation from 2000 to 2015 was performed. Patients were divided into two groups (group I: with anchoring stitch, group II: without anchoring stitch). Outcome measures including rectal prolapse, soiling, voluntary bowel control, and constipation, and Kelly Score were analyzed.

Results

There were thirty-four patients (group I, n = 20; group II, n = 14) undergoing laparoscopic assisted anorectal pullthrough during the study period. The median follow up duration for group I and group II was 60 months and 168 months, respectively. All patients had stoma performed prior to the operation. Both groups consisted of patients with high type (30% vs 57%, p = 0.12) and intermediate type (70% vs 43%, p = 0.12) anorectal malformation. Seven (35%) patients in group I and 3 (21%) in group II had concomitant vertebral and spinal cord pathologies (p = 0.408). The mean operative time was significantly shorter in group I (193 ± 63 min vs 242 ± 49 min, p = 0.048). Rectal prolapse occurred less in group I, 4 (20%) vs 9 (64%) patients in group II and was statistically significant (p = 0.008). Median time to development of rectal prolapse was 7 months in group I and 5 months in group II (p = 0.767). Mucosectomy was performed in 15% of group I and 36% of group II (p = 0.171). Soiling occurred less in group I (55% vs 79%, p = 0.167). Voluntary bowel control (85% vs 93%, p = 0.499) and constipation (55% vs 64%, p = 0.601) were comparable in both groups. 75% in group I and 71% in group II achieved a Kelly score of 5 or above (p = 0.823).

Conclusions

Our study showed application of anchoring stitch reduces rectal prolapse and soiling in laparoscopic assisted anorectal pullthrough.

Treatment Study–Level III.

Section snippets

Material and methods

Retrospective review of all children who had undergone laparoscopic assisted anorectal pullthrough for high-/intermediate-type anorectal malformation from 2000 to 2015 was performed. We divided the patients into two groups (group I: with anchoring stitch, group II: without anchoring stitch). To facilitate dissection of the rectum to a precise length that was just enough to be brought down to the anus without redundancy, we evacuated meconium from the sigmoid colon and rectum when the initial

Results

Thirty-seven patients had undergone LAARP during our study period. Three patients were lost to follow up immediately after LAARP and were excluded. There was a total of thirty-four patients (group I, n = 20; group II, n = 14) included in our study. The demographics of our patients were summarized in Table 1. The median follow up duration for group I and group II was 60 months and 168 months respectively. All patients had colostomy performed prior to the operation. Both groups consisted of patients

Discussion

LAARP has been practiced in our center since its publication by Georgeson in 2000 [1]. This technique allowed a precise placement of the rectum inside the sphincter complex without dividing and weakening the muscles, a superior exposure of the rectal fistulae and the surrounding pelvic structures [1], [6], [7], [8], [16], [17], [18]. Our center had previously reported an improvement in rectal resting pressure and rectoanal inhibitory reflex, less perirectal fibrosis and better sphincter

Conclusion

Our study showed that application of anchoring stitch reduces rectal prolapse and soiling in laparoscopic assisted anorectal pullthrough. Long term satisfactory defecative function was demonstrated in this follow up study.

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Cited by (19)

After anoplasty for anorectal malformations: Issues continue in adolescence and adulthood
2023, Seminars in Colon and Rectal Surgery
Advancements in the surgical and medical care of anorectal malformation (ARMs) have led to greater life expectancy and improved quality of life. Patients with ARM frequently experience fecal incontinence (17–77 %), constipation (23–87 %), and rectal prolapse (4–60 %). Upper urinary tract abnormalities occur in 40-83 %, leading to end-stage renal disease in 5–18 % and kidney transplantation in 2–8 %. Urinary incontinence occurs in 0–41 % of patients. Mullerian anomalies occur in up to 60 % of patients, and 36–41 % present with hematometra, which may impact fertility. Cryptorchidism is seen in 19 % and may lead to reduced paternity rates. Sexual dysfunction impacts 6–66 % of patients and coital debut is delayed, often due to fear of flatus or soiling. While fertility rates vary, childbirth is still possible. However, pregnancies carry a higher risk of miscarriage and premature delivery, and delivery via Cesarean section is recommended. Malignancy is uncommon, but patient anatomy is imperative to consider when assessing cancer risk, screening needs, and the impact of cancer treatment. Depression and anxiety occur in 80 %, with up to 15 % reporting suicidal ideation, yet only 12–40 % receive treatment. The high prevalence of ongoing complications highlights the need for continued multidisciplinary care after index ARM repair.
Rectal Prolapse Following Repair of Anorectal Malformation: Incidence, Risk Factors, and Management
2023, Journal of Pediatric Surgery
The incidence and optimal management of rectal prolapse following repair of an anorectal malformation (ARM) has not been well-defined.
A retrospective cohort study was performed utilizing data from the Pediatric Colorectal and Pelvic Learning Consortium registry. All children with a history of ARM repair were included. Our primary outcome was rectal prolapse. Secondary outcomes included operative management of prolapse and anoplasty stricture following operative management of prolapse. Univariate analyses were performed to identify patient factors associated with our primary and secondary outcomes. A multivariable logistic regression was developed to assess the association between laparoscopic ARM repair and rectal prolapse.
A total of 1140 patients met inclusion criteria; 163 (14.3%) developed rectal prolapse. On univariate analysis, prolapse was significantly associated with male sex, sacral abnormalities, ARM type, ARM complexity, and laparoscopic ARM repairs (p < 0.001). ARM types with the highest rates of prolapse included rectourethral-prostatic fistula (29.2%), rectovesical/bladder neck fistula (28.8%), and cloaca (25.0%). Of those who developed prolapse, 110 (67.5%) underwent operative management. Anoplasty strictures developed in 27 (24.5%) patients after prolapse repair. After controlling for ARM type and hospital, laparoscopic ARM repair was not significantly associated with prolapse (adjusted odds ratio (95% CI): 1.50 (0.84, 2.66), p = 0.17).
Rectal prolapse develops in a significant subset of patients following ARM repair. Risk factors for prolapse include male sex, complex ARM type, and sacral abnormalities. Further research investigating the indications for operative management of prolapse and operative techniques for prolapse repair are needed to define optimal treatment.
Retrospective cohort study.
II.
Assessing the previously repaired patient with an anorectal malformation who is not doing well
2020, Seminars in Pediatric Surgery
Citation Excerpt :
The amount of tension must be carefully assessed as too much could result in dehiscence and stricture. Others recommend application of an anchoring stitch to tack the rectum to the presacral fascia during laparoscopic assisted anorectoplasty (LAARP).31 Most of these maneuvers depend on the pelvic musculature, which if deficient will more likely allow for prolapse.28
In this review, the care of children with a previously repaired anorectal malformation is explored. We know that the surgical care of children with anorectal malformations is complex; however, despite an increased understanding of the congenital anomaly and significant technical advances in the operative repair, many of these children continue to have poor functional outcomes. In this article we focus on the common surgical complications, discuss typical presentations, consider appropriate investigations, and review the risks and benefits of revisional surgery in those patients that are ‘not doing well’ following their primary reconstruction.
Minimal dissection of posterior wall of rectum reduces rectal prolapse in laparoscopic assisted anorectal pull-through
2020, Journal of Pediatric Surgery
Citation Excerpt :
LAARP has been a feasible surgical option for ARM with rectourethral fistula since its description by Georgeson in 2000 [1]. Previous studies have described that LAARP has benefits over PSARP such as excellent visualization of the fistula, better cosmetic outcomes, decreased wound infection and pain, and better functional outcomes [8,13–15]. On the other hand, a few authors have raised a concern that LAARP shows more postoperative complications such as posterior urethral diverticulum and rectal prolapses than PSARP [9,10,16–19].
To determine if minimal dissection of the posterior wall of rectum can reduce rectal prolapse after laparoscopic assisted anorectal pull-through (LAARP) in male anorectal malformation (ARM) with rectourethral fistula.
Eighty-six male patients with ARM who underwent LAARP in our center between 2007 and 2018 were retrospectively analyzed. There were 45 cases of prostatic urethral fistula, 24 bulbar urethral fistulas, and 15 bladder neck fistulas. Two patients had no fistula. To prevent rectal prolapses, we markedly shortened the length of posterior rectal dissection from mid-2016. Dissection of posterior wall of rectum was performed minimally around the level of the fistula and the dissected portion of the posterior rectum was significantly shorter than the previous cases. For comparative analysis, patients were divided into two groups (before and after application of minimal dissection of posterior wall of rectum): Group A, from 2007 to mid-2016 and Group B, from mid-2016 to 2018.
There were 60 patients in Group A and 26 patients in Group B. Demographic characteristics were not significantly different between the two groups. The median follow-up duration was 52.4 months for Group A and 26.9 months for Group B. Group B had lower incidence of rectal prolapse (11.5%) than Group A (68.3%) (p < 0.001). Upon our subgroup analysis based on types of fistula, patients with recto-prostatic urethral fistula and recto-bulbar urethral fistula showed significant reduction in the incidence of rectal prolapse (both p < 0.001). However, patients with recto-bladder neck fistula showed no statistical significance (p = 0.264).
Minimal dissection of the posterior wall of rectum can reduce rectal prolapse in LAARP.
III. Retrospective Comparative Treatment Study
Assessing the long term manometric outcomes in patients with previous laparoscopic anorectoplasty (LARP) and posterior sagittal anorectoplasty (PSARP)
2018, Journal of Pediatric Surgery
Citation Excerpt :
The center of the external muscle sphincter was identified with an electrical stimulator to assist the pullthrough of the rectum into the most appropriate position. After anoplasty, an intracorporeal suture was applied to secure the rectum to the sacral fascia in order to prevent rectal prolapse [9]. Manometric study was carried out with a high resolution manometry system (Medical Measurement Systems [MMS]) as a day procedure without anesthesia.
The objective of this study is to compare the long term manometric outcomes in patients with previous laparoscopic anorectoplasty (LARP) and posterior sagittal anorectoplasty (PSARP).
This is a single-centered retrospective study and the participants were born with various types of anorectal malformation. Manometric assessment was carried out with high-resolution anorectomanometry performed as a day procedure. In addition, a seven-itemed bowel function score (BFS) was utilized to assess the functional outcomes.
A total of 30 patients were included in this study (PSARP = 14, LARP = 16) and the median follow up periods were 15.5 years and 9 years in the PSARP and LARP groups respectively (p = 0.06). The median value of BFS was significantly lower in the PSARP group (PSARP = 12.5, range: 8–18; LARP = 16, range: 10–20, p = 0.03). The median value of sphincteric resting pressure was 20 mmHg (range: 10–50 mmHg) in the PSARP group and 40 mmHg (range: 10–70 mmHg) in the LARP group (p = 0.05). There was no significant difference in following measurements: the percentage of patient having a normal sphincteric resting pressure (PSARP vs LARP = 50% vs 75%, p = 0.28); the median sphincteric squeeze pressure (PSARP vs LARP = 30 mmHg, range: 10–100 vs 50 mmHg, range: 20–140 mmHg, p = 0.08); the incidence of rectoanal inhibitory reflex (RAIR) (PSARP vs LARP = 42.9% vs 31.3%, p = 0.14) and the median value for volume of air to elicit the first anal sensation (PSARP vs LARP = 30 ml, range: 20–60 ml vs 40 ml, range: 20–80 ml, p = 0.18).
Anorectomanometry is a useful follow up study after anorectoplasty and majority of the patients with previous LARP could retain a normal sphincteric resting pressure during long term follow up. Comparing the two surgical approaches, patients with previous LARP could achieve a higher bowel function score as well as sphincter resting pressure in manometric assessment.
Level III.
Laparoscopic posterior rectopexy (Well's procedure) for full-thickness rectal prolapse following laparoscopic repair of an anorectal malformation: A case report
2018, International Journal of Surgery Case Reports
Citation Excerpt :
However, Jung et al., 2013 concluded that suture rectopexy is ineffective in treating RP secondary to LAARP repair of anorectal malformations [14]. Nevertheless, an anchoring stitch during LAARP has been advocated as an effective technique in preventing RP, as RP occurrence was significantly reduced in the group with anchoring stitch (20%) versus without anchoring stitch (64%) [15]. Overall, reported recurrence rates of RP after suture rectopexy substantially differ and range from 0% [16] to 100% [17].
Intractable full-thickness rectal prolapse (IRP) unresponsive to conservative treatment remains a major problem after anorectoplasty for high or intermediate anorectal malformation (ARM). Surgical management must aim for a permanent fixation of the rectum to the presacral fascia. While in children with IRP following ARM repair the optimal procedure has not been established yet, laparoscopic posterior mesh-rectopexy (Well’s procedure) has demonstrated efficacy in adults.
A male infant with intermediate ARM received laparoscopic-assisted anorectal pull-through at the age of 4 months. Three months later he developed mucosal prolapse and received multimodal conservative treatment. Because of progression into a full-thickness RP with ulcerations, the parents opted for surgical management. Well’s procedure was performed at the age of 4 years. Using four ports, the rectum was circumferentially mobilized down to the pelvic floor and pulled inside. A 5 × 5 cm prolene mesh was tacked to the sacrum, enveloped posteriorly 270° around the rectum, fixed with interrupted prolene sutures on both edges and carefully covered with peritoneum. Any redundant external mucosa was excised from a perineal approach. There were no intra- and postoperative complications. Within 1.5 years of follow-up the boy had voluntary bowel movements and was toilet trained. No prolapse recurrence could be observed nor provoked.
We present the first pediatric case of IRP secondary to laparoscopic ARM repair which has been successfully treated by combined Well’s procedure and perineal mucosal resection.
Well’s procedure is a successful technique and should be further explored in children with ARM and IRP.

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^☆: Conflicts of Interest and Source of Funding: No conflicts of interests or source of funding to be disclosed.

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PAPS PaperApplication of anchoring stitch prevents rectal prolapse in laparoscopic assisted anorectal pullthrough☆

Abstract

Background

Material and methods

Results

Conclusions

Section snippets

Material and methods

Results

Discussion

Conclusion

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

Semin Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

Laparoscopically assisted anorectal pull-through for high imperforate anus—a new technique

J Pediatr Surg

PAPS Paper
Application of anchoring stitch prevents rectal prolapse in laparoscopic assisted anorectal pullthrough☆