1. Anorectal malformations are congenital anomalies of the anus and rectum that occur in approximately 1 in 5,000 live births.
2. The document describes various classifications of anorectal malformations and discusses the embryological development of the condition.
3. Key surgical procedures for repair of anorectal malformations are described, including colostomy, posterior sagittal anorectoplasty, and pull-through operations. The repair approaches are discussed depending on the specific type of malformation.
POSTERIOR URETHRAL VALVES- Pediatric Surgery
• Dear viewers,
• Greetings from “ Surgical Educator”
• Today I have uploaded one more video in Pediatric Surgery/Pediatric Urology- “ Posterior Urethral Valves”
• Posterior Urethral Valves is the congenital cause for Bladder Outlet Obstruction, resulting in abnormal development of the kidneys as well as the bladder.
• In this video, I talked about the learning outcomes, introduction, etiopathogenesis, clinical features, investigations, differential diagnosis, treatment, follow-up and prognosis of “ Posterior Urethral Valves”
• I hope you will enjoy the video for its educational value.
• You can watch all my teaching videos in the following links
• surgicaleducator.blogspot.com youtube.com/c/surgicaleducator
• Thank you for watching the video.
Extended totally extraperitoneal repair (eTEP) is a novel technique that was first introduced by Jorge Daes in 2012 to address difficult inguinal hernias.
POSTERIOR URETHRAL VALVES- Pediatric Surgery
• Dear viewers,
• Greetings from “ Surgical Educator”
• Today I have uploaded one more video in Pediatric Surgery/Pediatric Urology- “ Posterior Urethral Valves”
• Posterior Urethral Valves is the congenital cause for Bladder Outlet Obstruction, resulting in abnormal development of the kidneys as well as the bladder.
• In this video, I talked about the learning outcomes, introduction, etiopathogenesis, clinical features, investigations, differential diagnosis, treatment, follow-up and prognosis of “ Posterior Urethral Valves”
• I hope you will enjoy the video for its educational value.
• You can watch all my teaching videos in the following links
• surgicaleducator.blogspot.com youtube.com/c/surgicaleducator
• Thank you for watching the video.
Extended totally extraperitoneal repair (eTEP) is a novel technique that was first introduced by Jorge Daes in 2012 to address difficult inguinal hernias.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
2. Introduction
• Anorectal malformation (ARMs) are the more
frequent congenital anomalies encountered in
paediatric surgery.
• Incidence : 1 in 5000 live births
Male > female
3. • In female: Rectovestibular fistula is the most
common
• In male :Rectourethral fistula is the most
common
• Most female have low or intermediate
anorectal malformations while the reverse is
true for males.
4. • Female babies usually have a fistula from the
terminal end of the bowel opening externally
while in male this fistula is usually well
hidden.
5. Embryology
• The hindgut gives
rise to the distal
third of the
transverse colon, the
descending colon,
the sigmoid, the
rectum, and the
upper part of the
anal canal.
6. • The hindgut enters the
posterior portion of the
cloaca, the future anorectal
canal; the allantois enters
the anterior portion, the
future urogenital sinus.
• The urorectal septum is
formed by merging of the
mesoderm covering the
allantois and the yolk sac.
7. • As caudal folding of
the embryo
continues, the
urorectal septum
moves closer to the
cloacal membrane.
8. • breakdown of the
cloacal membrane
creates an opening for
the hindgut and one
for the urogenital
sinus. The tip of the
urorectal septum
forms the perineal
body.
9. • Anorectal malformations may be caused by
abnormalities in formation of the cloaca
and/or urorectal septum.
• For example, if the cloaca is too small or
urorectal septum does not extend far enough
caudally, the opening of hindgut shifts to
anteriorly leading to the opening in urethra or
vagina.
13. • The terms high, intermediate and low are in
relation to the terminal end of the bowel
remaining above (high), with in
(intermediate) or below the levator ani
muscle.
19. Rectoperineal Fistulas
• Rectoperineal fistula is what traditionally was
known as a “low defect.”
• The rectum is located within most of the
sphincter mechanism. Only the lowest part of the
rectum is anteriorly mislocated .
20. • Sometimes,the fistula does not open into the
perineum but rather follows a subepithelial
midline tract, opening somewhere along the
midline perineal raphe, scrotum, or even at
the base of the penis.
• This diagnosis is established by perineal
inspection. No further investigations are
required.
21. • The terms covered anus, anal membrane,
anteriorly mislocated anus, and bucket-handle
malformations all are refer to perineal fistulas.
22.
23. Rectourethral Fistulas
Imperforate anus with a rectourethral fistula is the
most frequent defect in male patients.
The fistula may be located at
1.The lower (bulbar) part of the urethra
Lower urethral fistulas are usually associated with good-quality muscles, a
well-developed sacrum, a prominent midline groove, and a prominent anal
dimple.
1.The higher (prostatic) part of the urethra
Higher urethral fistulas are more frequently associated with poor-quality
muscles, an abnormally developed sacrum, a flat perineum.
24.
25. Recto-Bladder Neck Fistulas
• In this defect, the rectum opens into the
bladder neck.
• The patient usually has a poor prognosis for
bowel control because the levator muscles, the
striated muscle complex, and the external
sphincter frequently are poorly developed.
• The sacrum is often deformed and short
26. • The perineum is often flat, which is evidence of
poor muscle development.
• About 10% of males with anorectal atresia fall
into this category.
27. Imperforate Anus without Fistula
• Interestingly, most patients with this unusual
defect have a well-developed sacrum and good
muscles, and have a good prognosis in terms of
bowel function.
• The rectum usually terminates approximately 2
cm from the perineal skin.
28. Rectal Atresia
• In this extremely unusual defect in male
patients (~1% of the entire group of
malformations),the lumen of the rectum is
totally (atresia) or partially (stenosis)
interrupted.
• The upper pouch is represented by a dilated
rectum, whereas the lower portion is
represented by a small anal canal that is in the
normal location and is 1 to 2 cm deep.
29. These two structures may be
separated by a thin membrane or by
dense fibrous tissue.
30. • Patients with this defect have all the necessary
elements to be continent and have an
excellent functional prognosis.
• Because they have a well-developed anal
canal, they have normal sensation in the
anorectum and have almost normal voluntary
sphincters.
31. Rectoperineal Fistulas
• From the therapeutic and prognostic
viewpoint, this common defect is equivalent to
the perineal fistula described in the male
patient.
• The rectum is well positioned within the
sphincter mechanism, except for its lower
portion, which is anteriorly located.
• The rectum and vagina are well separated .
32.
33. Rectovestibular Fistulas
• Rectovestibular fistula is the most common
defect in girls and has an excellent functional
prognosis.
• The diagnosis is based on clinical examination.
A meticulous inspection of the neonatal
genitalia allows the clinician to observe a
normal urethral meatus and a normal vagina,
with a third hole in the vestibule, which is the
rectovestibular fistula .
34.
35. Imperforate Anus without Fistula
• This defect in female patients carries the same
therapeutic and prognostic implications as
described for male patients.
36. Persistent Cloaca
• This group of defects represents the extreme
in the spectrum of complexity of female
malformations.
• A cloaca is defined as a defect in which the
rectum, vagina, and urinary tract meet and
fuse, creating a single common channel.
37. • The diagnosis of persistent cloaca is a clinical
one.
• This defect should be suspected in a female born
with imperforate anus and small-looking
genitalia.
• Careful separation of the labia discloses a single
perineal orifice.
38. The length of the common channel varies from 1 to 7 cm.
This distance has technical and prognostic implications.
1. Short common channel less than 3 cm
2. Long common channel more than 3 cm
40. Examination
Pelvic floor
• Absence or presence of anal opening
• Position of anus – normal or anteposed
• Bulge in perineum on crying or straining
• Anal dimple
• Anal reflex
• Perineal groove
• Bucket handle deformity
• Meconium or mucus run ning up the
median scrotal raphe
43. Abdomen
• Large visible loop occupying more than half of
abdomen
• Palpable kidney/any other palpable lump –
solid or cystic
• Hydrocolpos(in girl) – palpable lump in lower
abdomen
53. General examination of neonate
(for VACTERL association)
Examination of spine.
Passage of nasogastric tube
Central cyanosis
Limb anomaly
Examination of genitalia
54. 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.
55. Midline groove
Anal membrane
Presence of presacral mass
No. of openings in vestibule
59. Transverse infracoccygeal sonogram shows the distal rectal pouch (R), which
passes through the puborectalis muscle (arrows), indicating low-type imperforate
anus. U = urethra
60. CT scan
Mainly required before surgery.
Clearly shows the anatomy of sphincter muscles,
Levator ani, muscle complex.
Delineates the rectal pouch and fistula.
Clearly shows the relationship between intestine
Surrounding muscles.
61. MRI
Provides better soft tissue imaging .
Better than CT in soft tissue imaging and no
radiation hazard.
Scan is expanded to include pelvis , kidneys and
spinal cord in case of associated anomalies.
Post operatively it clearly shows whether the pulled
through intestine is within levator ani sling or not
62. High-pressure distal colostography
• Before the definitive repair, distal
colostography is performed.
• It is the most valuable and accurate diagnostic
study to define the anatomy of the anorectal
malformation.
63. • Water-soluble contrast medium is instilled
into the distal stoma, which fills the distal
intestine and enables demonstration of the
location of the blind rectum and the precise
site of a rectourinary fistula.
• The contrast medium must be injected with
considerable hydrostatic pressure under
fluoroscopic control.
64. • The use of a Foley catheter is recommended; it is
passed through the distal stoma, the balloon is
inflated (2–5 mL), and it is pulled back as far as
possible to occlude the stoma during the
injection of the contrast medium.
• This maneuver permits to overcome the muscle
tone of the striated muscle mechanism, fill the
rectum, and demonstrate the urinary fistula
when present
66. COLOSTOMY
• Descending colostomy is preferred.
• The colostomy is constructed through a left
lower quadrant oblique or transverse incision.
• The proximal stoma is exteriorized through
the upper and lateral part of the wound and
the mucous fistula is placed in the medial or
lower part of the wound.
67. • The colostomy should be made in the mobile
portion of the colon, immediately distal to the
descending colon taking advantage of its
retroperitoneal attachments, and the mucous
fistula is made very small to avoid prolapse.
• During the opening of the colostomy, the distal
intestine must be irrigated to remove all the
meconium, preventing the formation of a
mega-sigmoid.
68.
69. Advantages of descending colostomy
• Mechanical preparation of the distal colon
before the definitive repair is easy due small
length of remaining segment.
• Due to shorter distal segment in patient with
recto-urethral or recto-vasical fistula urine is
not accumulate in distal segment of
colon.(which leads to development of
metabolic acidosis)
70. • Less chance of development of
megarectosigmoid.
• The incidence of prolapse in the proximal limb
of descending colostomies is almost zero.
71. POSTERIOR SAGITTAL ANO-
RECTOPLASTY
• All anorectal malformations benefit from the
use of the posterior sagittal approach.
• The length of the incision depends on the
specific defect.
• The patient is placed in the prone position
with the pelvis elevated.
73. • An incision that starts in the lower portion of
the sacrum and extends anteriorly to the anal
sphincter.
• Recto vestibular and recto perineal fistula
requires smaller incision so, called limited
posterior sagittal ano rectoplasty and minimal
posterior sagittal ano rectoplasty respectively.
74. Repaires in boys
Rectoperineal fistula
• The repair of these defects consists of a small
anoplasty with minimal mobilization of the
rectum, sufficient for it to be transposed and
placed within the limits of the sphincter.
• It is done during the neonatal period without
a colostomy.
75. • These patients have an excellent prognosis.
• if they have significant associated spinal or
sacral problems an alternative approach, a
Pott’s transplant anoplasty, whereby the
majority of the perineal body is preserved, the
mobilized fistula is brought through a separate
incision which is confined to the size of the
future neoanal canal.
76. Rectourethral fistula
• Most important thing in these cases are to put
per urethral catheter.
• To avoid the catheter to be entered in rectum,
the catheter must be intentionally directed
anteriorly by the use of a lacrimal probe
inserted in the distal tip of the catheter to find
its correct path.
77. Rectobladderneck fistula
• As it is very high defect both approach (through
perineum and through abdomen) is needed.
• A plasty of the distal dilated portion of the
rectum is necessary in some cases to reach the
perineal skin.
• It is also called as abdomino perineal pull through
operation.
78. Imperforate anus without fistula
• About 5 percent of patients have imperforate
anus without a fistula.
• In both boys and girls, the rectum lies about 2
cm from the perineal skin.
79. • The rectum must be carefully separated from
the urethra because the two structures have a
common wall. The rest of the repair must be
performed as described for the rectourethral
fistula type of defect
80. Rectal atresia and stenosis
• These defects are repaired through a posterior
sagittal approach.
• The entire sphincteric mechanism is divided in
the midline. The narrowed area of the distal
rectum is opened posteriorly.
81. • The posterior rectum is mobilized to reach the
anal skin. No anterior dissection is needed.
The sphincter mechanism posterior to the
rectum is reconstructed.
• Any presacral mass deals simultaneously in
the same operation.
82. Repairs in girls
Rectoperineal fistula
• The treatment of rectoperineal fistula in girls
is the same as that discussed for boys, except
of course that the anterior rectal wall is
mobilized off the area behind the vagina.
83. Rectovestibular fistula
• Incision in this defect is usually shorter as compare to
recto urethral fistula in boys.
• Starting from posteriorly sphincter mechanism is
divided till reach rectal fascia which is helpful in
indenting the plane of dissection.
• Than we go laterally and than anteriorly using this
plane.
84. • Because the rectum and vagina have single wall it
is divided using needle cautery.
• The most common error in performing this
operation is incomplete separation of the vagina
and rectum.
• This may create a tense anastomosis between
the rectum and the skin, which may provoke
dehiscence and recurrence of the fistula
85. • The anterior limit of the external sphincter is
identified using electrical stimulation and the
anterior edge of the muscle complex are
reapproximated as previously described,
creating the perineal body.
86. Rectovaginal fistula
• Imperforate anus with a true rectovaginal
fistula is extremely rare.
• A true rectovaginal fistula requires a full
posterior sagittal incision.
87. • The operation is essentially the same as that
described for a rectovestibular fistula, except
that it is necessary to dissect much more of
the rectum to gain enough length to pull it
down to the perineum.
94. PSARP IN FEMALE
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
94
97. 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
99. 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.
100.
101. 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
102. Post operative care
• In cases of rectourethral fistula in boys, the
urethral catheter is left in place for 7 days.
• If the urethral catheter is accidentally
dislodged, the patient can be observed for
spontaneous voiding, which usually occurs.
Attempts to reintroduce a urethral catheter
can be dangerous and must be avoided.
103. • Intravenous antibiotics are administered for 24
hours. An antibiotic ointment is applied to the
anoplasty for 5 days.
• The patient is discharged after 2 days in cases of a
posterior approach without a laparotomy or
laparoscopy, and after 3–5 days in cases of an
abdominal approach.
104. • The parents are instructed to keep the incision
clean, not to wipe, and to apply antibiotic
ointment for 1 week.
• Two weeks after the operations, anal
dilatations are started. On the first occasion, a
dilator that fits loosely into the anus is used to
instruct the parents, who must carry out
dilatation twice daily.
105. • Every week, the size of the dilator is increased
until the rectum reaches the desired size,
which depends on the patient’s age.
• Once the desired size is reached, the
colostomy can be closed.
106. • Frequency of dilatation should be reduce in
following schedule :
• at least once a day for one month; every third
day for one month; twice a week for one
month; once a week for one month; and every
2 weeks for three months.
107.
108.
109. • Initially patient having diaper rash due to
multiple bowel movement which is converted
to 2 or 3 bowel movement per day in 6
months.
• Patient with 2 to 3 bowel movement in
day,with some feeling on having bowel
movement have good prognosis and responds
to toilet training.
111. Wound infection
• Wound infections and mild dehiscences of the
posterior sagittal incision can occur. The
infection usually affects only the skin and
subcutaneous tissue, can be resutured, and
will heal with local care.
112. Anal strictures
• A direct correlation exists with intraoperative
devascularization of the distal rectum or
excessive tension on the anoplasty.
• Other cause of anal stricture is that protocol
of serial anal dilatation is not followed.
113. Constipation
• This is the most common functional disorder
observed in patients with anorectal
malformations, particularly prevalent in lower
malformations; rectoperineal, bulbar, and
vestibular fistulas
114. Transient femoral nerve pressure
• Excessive pressure on the groin during a
posterior sagittal operation can lead to this
problem, which can be avoided by adequate
cushioning of the patient’s pelvis while in the
prone position.
115. Neurogenic bladder
• Neurogenic bladder following a posterior sagittal
approach in patients with favorable anatomy can occur
due to nerve damage during the rectal dissection.
• In addition, placing Weitlander’s retractors deeper than
is necessary may compress the nerves that come from
the sacral area,causing a neurogenic bladder.
116.
117. Management of complication
Minimal to no potential for bowel control
• These are patients who have a under developed
sacrum, associated spinal problem, poor
sphincters, a very high defect, and a poor bowel
movement pattern.
• The best treatment for these patients is a bowel
management program with success rate of 95%
118. • Patient in this group are divided in to 2
category,
Constipated
• These patients have undergone a procedure in
which the rectum was preserved.
• Contrast study shows a megarectosigmoid.
• Management consists of the use of enemas with
volumes of fluids large enough to clean a large
rectosigmoid colon.
• These patients don’t need any strict diet
recomandation
119. Patients with a tendency to have loose stool
• This group of patients has undergone a type of
procedure in which their original rectosigmoid
colon was resected.
• A contrast enema shows that the colon runs
straight from the splenic flexure down to the anus.
• Management consists of a small enema, a very
strict constipating diet and agents that slow
colonic motility, such as loperamide and water-
soluble fiber.
120. Potential for bowel control
• These patients were born with a favorable
type of defect (rectovestibular fistula,
rectoperineal fistula, rectourethral bulbar
fistula), a good sacrum, a normal spine, and a
good sphincteric mechanism, and underwent
an operation that placed the rectum in the
correct position.
121. • In addition, these patients have a good bowel
movement pattern.
• Management of this patient requires
behavioral modification (to have voluntary
bowel movement) and sometimes stimulant
laxatives.
122. Candidates for a reoperation
• These patients were born with a favorable
type of defect.
• They underwent an operation that placed the
rectum in the wrong place or left it strictured
or prolapsed.
• Management of this patient requires
repositioning of rectum with in sphincter
mechanism.
123. REFERENCES
• Bischoff A, Tovilla M. A practical approach to the management of pediatric
fecal incontinence. Seminars in Pediatric Surgery 2010; 19: 154–9.
• Falcone RA, Levitt MA, Peña A, Bates MD. Increased heritability of certain
types of anorectal malformations. Journal of Pediatric Surgery 2007; 42: 124–
8.
• Hong AR, Rosen N, Acuña MF et al. Urological injuries associated with the
repair of anorectal malformations in male patients. Journal of Pediatric
Surgery 2002; 37: 339–44.
• Peña A, Grasshoff S, Levitt MA. Reoperations in anorectal malformations.
Journal of Pediatric Surgery 2007; 42: 318–25.
• Peña A, Migotto-Krieger M, Levitt MA. Colostomy in anorectal malformations a
procedure with serious but preventable complications. Journal of Pediatric
Surgery 2006; 41: 748–56.
• Shaul DB, Harrison EA. Classification of anorectal malformations – initial
approach, diagnostic tests, and colostomy. Seminars in Pediatric Surgery 1997;
6: 187–95.
124. • Pena A, Devries PA: Posterior sagittal anorectoplasty: important technical
considerations and new applications. J Pediatr Surg 1982, 17(6):796-811.
• Pena A: Posterior sagittal approach for the correction of anorectal
malformations. Adv Surg 1986, 19:69-100.
• Pena A, Hong A: Advances in the management of anorectal
malformations. Am J Surg 2000, 180(5):370-376.
• Rintala RJ, Lindahl HG: Posterior sagittal anorectoplasty is superior to
sacroperineal-sacroabdominoperineal pullthrough: a long-term follow-up
study in boys with high anorectal anomalies. J Pediatr Surg 1999,
34(2):334-337.
• Pena A: Anorectal Malformations: Operative Pediatric Surgery Edited by:
Ziegler, Azizkhan. Gauderer & Weber. Boston: Appleton & Lange; 2005.
• Pena A: Cloacal Repair. In Atlas of Pediatric Urologic Surgery. Chapter63
Edited by: Hinman F. Philadelphia, PA: W.B. Saunders Company; 1994:322-
324.
125. • Pena A, Levitt M: Anorectal malformations. In Pediatric Surgery and
Urology: Long term outcomes 2nd edition. Edited by: Stringer M, Oldham
K, Mouriquand PDE. Cambridge: Cambridge University Press; 2007:401-
415.
• Levitt MA, Pena A: Pitfalls in the management of newborn cloacas. Pediatr
Surg Int 2005, 21(4):264-269.
• Rosen NG, Hong AR, Soffer SZ, Rodriguez G, Pena A: Rectovaginal fistula: a
common diagnostic error with significant consequences in girls with
anorectal malformations. J Pediatr Surg 2002, 37(7):961-965.
• Levitt MA, Stein DM, Pena A: Gynecologic concerns in the treatment of
teenagers with cloaca. J Pediatr Surg 1998, 33(2):188-193.