A Case Presentation of An Atresia Ani

1. CASE Atresia
Ani

2. Introduction

3. Embryology

4. Types of Malformations
Anorectal malformations occur in approximately 1 in 5000 newborns. The
most frequent defect in males is an imperforate anus with rectourethral fistula
followed in frequency by rectoperineal fistulas.
The rectobladderneck fistula defect occurs in 10% of male patients and
represents the highest type.
The most frequent defect in female patients is rectovestibular fistula, followed
by rectoperineal fistula. Persistent cloaca is the third most common defect
seen in females, which used to be considered a very unusual defect.
Rectovestibular fistulas were also frequently erroneously called rectovaginal
fistula, which itself is an almost nonexistent defect.
Imperforate anus without a fistula occurs in 5% of all anorectal malformations,
both in males and in females, which is the only truly " imperforate" type. It is a
unique defect in which the rectum is reliably located about 2 cm above the
perineum, and in a male, is found at the level of the bulbar urethra.

5. Imperforate Anus
without Fistula

6. The 24
Hours
In addition, the rectum is surrounded by a striated funnel- like
sphincter mechanism with a significant tone.
The muscle tone keeps the most distal part of the rectum collapsed,
until the intraluminal pressure is high enough to overcome the muscle
tone.
This occurs usually after 24 h
Therefore, all imaging diagnostic tests aimed to detect the location of
the blind rectum are inaccurate when performed before 24 h of life.
Spend the first 24 h of the baby’s life in trying to rule out serious
associated conditions and try to determine the location of the rectum
The cross-table lateral film renders a reliable image when it is taken
24 h post birth.
When the rectal bubble is located well below the coccyx, the surgeon
knows where to expect to find the rectum
At birth, most
babies with anorectal
malfor-mations do not have
a distended bowel and
abdomen. It takes 18/24 h
for the rectosigmoid to
become distended.

9. Imaging
The first 24 h of life, before making the decision to open a colostomy or to
perform a primary repair, represents a window of opportunity to diagnose
potential associated defects.
The chest film taken during the first 24 h of life also allows us to
see the integrity of the thoracic vertebra and ribs. In addition, it
helps us in the diagnosis of esophageal atresia and potential
cardiac malformations
The abdominal x-ray film allows us to see and rule out the possibility of
hemivertebra. The early detection of these types of malformations is
relevant to establish the functional prognosis in these babies. The
abdominal film must include an AP view of the sacrum It is also
important to take a lateral abdominal film that allows a more accurate
measurement of the sacral ratio
Traditionally, the number of sacral vertebrae is counted to
evaluate the quality of the sacrum. Most pediatric surgeons
agree that when a patient has less than three sacral vertebrae,
the prognosis for bowel and urinary control is not good.

10. Imaging

11. Imaging

12. Imaging

13. Imaging

14. The Colostomy

15. Loop Colostomy

16. Stoma
Locations
Right transverse colostomy (right upper
quadrant)
Left transverse colostomy: The left portion of the
transverse colon is divided, and the stoma(s) is
opened in the left upper quadrant of the abdomen
Descending colostomy: The bowel is divided immediately
distal to the descending colon, in the first mobile portion of
the sigmoid, and the stoma is usually opened in the left
lower quadrant of the abdomen
Sigmoid colostomy: The sigmoid colon is divided, and
the stomas are usually opened somewhere in the
lower abdomen. The problem with this kind of
colostomy is that there is a possibility of creating the
stoma too distal in the colon, leaving a very short
piece of bowel available for the pull-through.

17. Divided
Descending
Colostomy
It effectively diverts the entire fecal stream.
It significantly decreases the chances of urinary tract infection.
It significantly decreases the chances of urinary tract infection.
It avoids the formation of megarectosigmoid because it allows the
irrigation and cleaning of the distal bowel and avoids distal fecal
spillage (meconium)
It virtually eliminates the chances of hyperchloremic acidosis from
resorption of urine from colon (recto-urinary fistulas patient)
It does not interfere with the pull-through.
It will not prolapse when done properly.
In newborn babies with
anorectal malformations, in
whom we consider that a
colostomy is indicated, we
prefer to open a descending
colostomy, with widely separa-
ted stomas, located in the left
lower quadrant of the
abdomen:

18. The Creation (Surgical Technique)

19. The Creation (Surgical Technique)

20. The Creation (Surgical Technique)

21. The Creation (Surgical Technique)

22. The Creation (Surgical Technique)

23. The Creation (Surgical Technique)

24. The
Complication
Immediate complications include dehiscence of the stoma,
retraction, and infection.
These three complications usually occur together.
This represents a catastrophe usually related to a poor technique,
a colostomy opened in a very sick patient, or both.
A tense anastomosis between the bowel and the abdominal wall,
plus a devascularization of the bowel, may explain the retraction
and dehiscence.
A poor surgical technique with severe contamination may explain
the infection
Late complications include Parastomal hernia: This is also a
technical problem that is avoidable by using a meticulous surgical
technique.
Complications in colostomies
are divided into immediate and
late.

25. The Complications

26. The Complications

27. The Complications

28. The Complications

29. Prolapse Management

30. Case

31. Identity

32. Main complaint

33. History taking

34. Physical Examination

35. Physical Examination

37. Hematologi Kimia Klinik
Hasil Nilai Rujukan Hasil Nilai Rujukan
Leukosit 15.980 6.00-18.00 10^3/µL GDS 89 <200 mg/dL
Eritrosit 4.25 3.10-4.30 10^6/µL Albumin 3.2 3.5-5.5 g/dl
Hemoglobin 18.1 13.4-19.8 g/dl Ureum 35.6 19.3-49.2 mg/dl
PLT 168.000 150-450 10^3/µL Creatinin 0.4 0.7-1.3mg/dl
Hematokrit 52.5 28.0-42.0 % SGOT <40 u/L
SGPT <41 u/L
Bilirubin Total <1.0 mg/dl
Bilirubin Direct 0.3-1.0 mg/dl
BT 1-6 Menit Bilirubin Indirect 0.0-0.8 mg/dd
CT 1-15 menit Alkali Phospatase 40-129 U/L
Hemostasis Electrolyte
APTT 26.7 24-36 detik Natrium 136 135-155 mmol/L
PT 15.5 10.8-14.4 detik Kalium 4.6 3.6-5.5 mmol/L
INR 1.10 Cloride 109 98-108 mmol/L
Imuno-Serologi Imuno-Serologi
Rapid Antigen
SARS-CoV-2
Negatif Negatif Ab HIV Non Reaktif Non Reaktif
Dengue Ig G Negatif HBs Ag Non Reaktif <0.09 COI
Dengue Ig M Negatif ASTO <200 IU/ml
Procalcitonin
Elecsys
<=0.020 ng/ml CRP Kuantitatif <=5 mg/L

38. Working Diagnose

39. X-Ray

40. Echocardiography

41. Intraoperative

42. SUBTITLE SUBTITLE

43. Diagnose

44. Follow up
DAY 9 DAY 12
DAY 5

45. Thank You