Management of Ano-rectal Malformations in Children

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Ano-rectal malformation in children should be detected and corrected very early in order to achieve normal physiological parameters in later life.

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Management of Ano-rectal Malformations in Children

  1. 1. Anorectal Diseases in Children Prof. A. N. Gangopadhyay Head Department of Paediatric Surgery IMS, BHU
  2. 2. Anorectal disease in children • Congenital Anorectal Malformation • Acquired diseases
  3. 3. Classification of anorectal anomalies in boys Perineal (cutaneous) fistula Rectourethral fistula Rectovesical fistula Imperforate anus without fistula Rectal atresia Bulbar Prostatic
  4. 4. Classification of anorectal anomalies in girls Perineal (cutaneous) fistula vestibular fistula Persistent colaca Imperforate anus without fistula Rectal atresia
  5. 5. Krickenbeck Classification 2005) Major clinical groups variants  Perineal (cutaneous) fistula  Rectourethral fistula atresia/stenosis  Bulbar fistula  Prostatic  Rectovesical fistula  Vestibular fistula  Cloaca  No fistula  Anal stenosis 6 Rare/regional · Pouch Colon · Rectal · Rectovaginal · H type fistula · Others
  6. 6. Management protocol of Congenital Anorectal Malformation in Boys
  7. 7. Management protocol of Congenital Anorectal Malformation in Girls
  8. 8. Approach to a case of ARM  History of neonate  Clinical examination  Investigation
  9. 9. History Abdominal distension and non-passage of stool per anus.
  10. 10. General examination of neonate (for VACTERL association)      Examination of spine. Passage of rigid nasogastric tube Central cyanosis Limb anomaly Examination of genitalia
  11. 11. Examination of perineum  Presence or absence of anus.  Gas/meconium from perineum  Presence of vaginal and urethral opening.  Size of vaginal introitus.  Size of anal dimple.  Position of anus.
  12. 12.     Midline groove Anal membrane Presence of presacral mass No. of openings in vestibule
  13. 13. Imaging Studies  Babygram  Invertogram(1930)  Crosstable lateral radiography(1983)  USG abdomen+pelvis(to rule out genitourinary anomalies)  -- Ultrasonography a)transperineal (1996)  b)infracoccygeal (2003)  MCU,IVP  CT Scan,MRI
  14. 14. Invertogram Above PC line – High type ARM Between PC line and I point – Intermediate type ARM Below I point – Low type ARM
  15. 15. Crosstable lateral radiograph of a patient
  16. 16. Transverse infracoccygeal sonogram shows the distal rectal pouch (R), which passes through the puborectalis muscle (arrows), indicating low-type imperforate anus. U = urethra
  17. 17. CT scan  Mainly required before redo surgery.  Clearly shows the anatomy of sphincter muscles,  levator ani, muscle complex.  Delineates the rectal pouch and fistula.  Clearly shows the relationship between intestine  and surrounding muscles.
  18. 18. MRI  Provides exquisite soft tissue imaging in all three plane.  Better than CT in soft tissue imaging and no radiation hazard.  Scan is expanded to include pelvis , kidneys and spinal cord.  Clearly shows whether the pulled through intestine is within levator ani sling or not
  19. 19. PSARP Position
  20. 20. PSARP PROCEDURE STAY SUTURES LIGATION OF FISTULA RECTAL POUCH POUCH PERINEAL DISTANCE
  21. 21. PSARP PROCEDURE AFTER MOBILIZATION FINAL PICTURE AFTER CLOSURE FOLLOW UP PICTURE
  22. 22. ABDOMINOPERINEAL pull-through operation  Lower bowel is mobilized  New passage is created through the pelvic floor keeping close to the urethra  Fistulous tract is divided and ligated  Bowel can be pulled down and its mucosa stitched to the skin of the newly formed anus.  Daily dilatation will be required for at least 3 months
  23. 23. Abdominoperineal pull through
  24. 24. ASARP  involves a midline incision from the fistula to the putative site of the anus.  division of the muscles in the midline,separation of the rectum from the vagina under vision  placement of the rectum within sphincteric complex and reconstruction of the perineal body.  Indications:  All low and intermediate type of abnormality in females  Revision surgery following cutback operations 27
  25. 25. ASARP-procedure 28
  26. 26. 29
  27. 27. Laparoscopically assisted anorectal pull through (LAARP) for high ARM  Advantages:  LAARP allows the surgeon to treat a high lesion like a low lesion.  No need to divide the muscle complex from below.  Immediately after the procedure strong and symmetric contraction of the sphincter around the neoanus can be seen.
  28. 28.  It also avoids the,complication and multiple procedures associated with colostomy.  More rapid return of bowel function  Improved cosmetic appearance  Shorter postoperative recovery  Decreased postoperative complications
  29. 29. Acquired conditions of the anorectum & perineum in children • • • • • • • Anal fissure Rectal polyp Rectal prolapse Perianal abscess and fistula Inflammatory bowel disease Straddle injuries Labial adhesions
  30. 30. Presentation of rectal bleeding in children Neonatal Necrotizing enterocolitis Volvulus with ischaemia Haemorrhagic disease of the newborn (vitamin K deficiency) Anal fissure Swallowed maternal blood Small amount of bright blood in a well child Anal fissure (most common) Rectal polyps Unrecongized rectal prolapse Haemorrhoids (idiopathic)
  31. 31. Presentation of rectal bleeding in children ill child with an acute abdominal condition Intussusception Gastroenteritis Henoch-Schonlein purpura Major hemorrhage from gastrointestinal tract Oesophageal varices Peptic ulcer Meckel’s diverticulum Tubular duplications Chronic illness with diarrhoea Crohn’s disease Ulcerative colitis Non-specific colitis
  32. 32. Perianal and perirectal abscesses • Develop primarily in infants • As a tender mass lateral to the anal opening • Equal incidence in male and female infants • Younger than 12 months • Sitz baths one third of abscesses thus treated resolve, two thirds require surgical drainage or drain spontaneously. • 40 to 50% of perianal abscesses progress to fistula in ano.
  33. 33. Fistula in ano • Fistula in ano predominantly in male • After two or more flare-ups of a perianal abscess that either continues to drain or to form a small pustule that ruptures only to from again • Located lateral to the anus • Occasionally two fistulas occur simulataneoulsy • Theory fistula in ano results from infection in abnoramlly deep crypts that are under the influence of androgenes
  34. 34. Fistula in ano • It has been postulated that in addition to the fistulotomy or fistulectomy, multiple cryptotomy should be carried out to prevent serial fistulization • The wound is left open which provides for some distress on the part of the parents but little discomfort on the part of the child.
  35. 35. Fissure in ano • Fissure in ano develops in toddlers whose diet changes from liquid to solid & whose stool consistency changes from soft to firm. • A period of constipation often precedes a hard bulky stool that results in a posterior midline anal tear. • The discomfort associated with a fissure in ano often leads to further constipation, which in turn, aggravates the fissure with each stool and prevents healing.
  36. 36. Fissure in ano • The diagnosis is made through the history of blood streaking on the stool, child crying during bowel movements. • Recognition of a split in the skin of the anus • Excision is rarely necessary, mostly treated by sitz baths and with stool softener. • Fissure in ano in an older child or a teenager very often is associated with chronic inflammatory bowel disease, usually Corhn’s disease
  37. 37. Hemorrhoids • Hemorrhoids are uncommon in the pediatric population unless associated with portal hypertension • Currently the most common etiology is cystic fibrosis (CF) • Rarely is it necessary to perform surgical procedures on these hemorrhoids • Symptomatic therapy reduces the likelihood of bleeding and pruritus.
  38. 38. Hemorrhoids • Surgical treatment of hemorrhoids: Sphincter preservation is paramount, according to bornemeier. • The sphincter [ani] apparently can differentiate between solid fluid and gas. No other muscle in the body is such protector of the dignity of man yet so ready to come to his relief. • A muscle like this is worth protecting • Thrombosed hemorrhoids resulting from prolonged extrusion require incision and evacuation of clot.
  39. 39. Rectal Prolapse • Rectal prolapse is relatively common in young children and usually occurs as a result of a diarrheal illness. • Constipation, wasting illness, or malnutrition • Prolapse is probably a herniation of the rectum • Most cases through a dilated levator mechanism.
  40. 40. Rectal Prolapse • Straining at stool and long periods of time sitting on the toilet. Due to protracted diarrhea or constipation, allows stretching of the pelvic diaphragm. • The suspensory vessels and other less well defined suspensory structures of the rectum, resulting in prolapse. • What appears to be rectal prolapse is an intussusception of the sigmoid colon.
  41. 41. Rectal Prolapse • If the prolapse is prevented from recurring, the muscle fibers shorten and the situation may be selflimiting. • Improvement in nutrition may also result in a spontaneous resolution of rectal prolapse. • Daignosis is usually made by the parent who sees the rosette of rectum or sigmoid when the child complains of discomfort at the anus. • Bleeding is occasionally noted as the primary symptom
  42. 42. Rectal Prolapse • The prolapse either reduces spontaneously as the child gets off the toilet or the parent pushes it back. • Most often the prolapse is not seen during examination because the patient does not relax the anus and strain sufficiently.
  43. 43. Treatment • The non-operative treatment of rectal prolapse consists of attempts to alter the stool disorder that led to the prolapse. • Eliminating the cause of intractable diarrhea or chronic constipation seems to be the most practical approach.
  44. 44. Treatment • Surgical therapy has taken a number of forms. • In Europe the Middle East and Asia perianal cerelage has been used frequently because it can be done as an outpatient procedure. • It tightens the anal and prevents prolapse from recurring while the musculature of the pelvis reestablishes its more normal relationships • Sclerotherapy using 30% saline, 5% phenol or 25% glucose injected into the retrorectal space produces an inflammatory response and scar that theoretically prevents the rectum from sliding downward
  45. 45. Treatment : other modalities • Quadrant cauterization & taping • Endorectal cauterization or mucosal stripping • Suspension & plication procedures • Open sclerosing procedure by packing gouze for 10 days • Transanal suture fixation of the rectum
  46. 46. Recent operative techniques (Remove the coccyx, narrow the muscular hiatus & suspend the rectum)
  47. 47. Rectal Trauma • Two mechanisms 1. Accidental impalement injury Tree branch, bicycle crossbar and straddle injuries 2. Sexual abuse Chronic stellate laceration of the anus with lymphedema, condylomata
  48. 48. Examination • Difficult to examine because of discomfort • Foreign object penetration- VCU, Rectal examination & Sigmoidoscopy under GA • Sexually abused does not require radio graphic examination and anaesthesia
  49. 49. Accidental Injures
  50. 50. Sexual Abuse
  51. 51. Treatment • Penetrating rectal injuries require diverting colostomy followed by repair of extensive perianal lacerations at the same time to re approximate the sphincter muscle mechanism. • Sexual abuse interruption of the abuse pattern but diverting colostomy very rarely required
  52. 52. Role of Ksharasutra in Management of Anorectal Disease in Children Prof A. N. Gangopadhyay Head, Department of Pediatric Surgery IMS, BHU, Varanasi
  53. 53. Types of Disorder • Congenital Anorectal Malformation • Acquired Anorectal Disease
  54. 54. Congenital Anorectal Malformation • High type Anorectal Malformation • Intermediate type Anorectal Malformation • Low type Anorectal Malformation • Anteriorly placed anus (ectopic anus) • H – type anovestibular or recto-vaginal fistula
  55. 55. Acquired Anorectal Disease • Fistula in ano • Fissure in ano • Hemorrhoids • Rectal prolapse
  56. 56. Congenital Anorectal Malformation Management • Most of the congenital anorectal malformation were treated by surgery either by PSARP or Abdominoperineal pull through operation. • The H – Type fistula can be treated by Ksharasutra
  57. 57. Advantage of Ksharasutra • It does not require mobilization of anorectum and vazina • Lesser hospital stay • Usually 3 – 4 changes of Ksharasutra were require for completely removing this fistulous communication. • In our centre we have managed 127 cases of H-type fistula in which 85 were treated with Ksharasutra. • 42 cases were treated with surgery.
  58. 58. Acquired Anorectal Disease • About 152 cases of acquired fistula in ano were treated in last 30 years. • 77 of them treated with Ksharasutra and 75 were managed with surgical excision.
  59. 59. Patients treated by different modalities
  60. 60. Complications
  61. 61. Advantage of Ksharasutra Ksharasutra Surgery Post – operative care Minimal Required Post-operative wound Minimal Large and usually heals by secondary intention Recurrence Very rare Known Hospital stay Nil Few days
  62. 62. Operative steps for fistula in ano - Ksharasutra
  63. 63. Operative steps for fistula in ano – Ksharasutra contd.
  64. 64. Operative steps for fistula in ano – Ksharasutra contd.
  65. 65. Operative steps for fistula in ano – Ksharasutra contd.
  66. 66. Operative step for fistula in ano- open method
  67. 67. Operative step for fistula in anoopen method contd.
  68. 68. Operative step for fistula in ano- open method contd.
  69. 69. Thank You

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