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Original article 19

Fistulectomy and anoplasty for low imperforate anus with


anoperineal fistula in boys
Ibrahim Ali Ibrahim

Purpose To present our operative technique for the longer than 3 years. Twenty-one patients had a good score
treatment of anoperineal fistula, discussing its advantages and two had a fair score. No patients had a poor score.
in comparison with other methods of treatment.
Conclusion Our approach has the following advantages:
Patients and methods This study included 35 neonate (i) the operation is simple and easy to perform. (ii) It has
boys, 34 were full term and one was preterm. Their age a minimal complication rate, with a good cosmetic and
ranged from 1 to 4 days, and they were diagnosed to have functional outcome. (iii) Anorectal function was not
low imperforate anus with anoperineal fistula, without adversely affected in patients with anterior position of
associated major anomalies. They were treated by the anal orifice. Ann Pediatr Surg 7:19–22
c 2011 Annals of
fistulectomy and anoplasty. Pediatric Surgery
Annals of Pediatric Surgery 2011, 7:19–22
Results The operative time ranged from 25 to 40 min. The
operation was completed successfully in all patients. All Keywords: anorectal anomalies, anoperineal fistula, low imperforate anus
patients started gradual oral feeding 2 h postoperatively
Department of General Surgery, Pediatric Surgery Unit, Faculty of Medicine,
and were discharged after 24–48 h on oral feeding. Assiut University, Assiut, Egypt
Postoperative stricture occurred in two patients, one Correspondence to Ibrahim Ali Ibrahim, Department of General Surgery, Pediatric
responded to dilation and the other needed redo surgery Surgery Unit, Faculty of Medicine, Assiut University, Assiut, Egypt
by a simple cutback technique. Continence could be Tel: + 00 20 105801291; fax: + 00 20 882414381

assessed in 23 patients whose follow-up periods were Received 10 May 2010 Accepted 15 June 2010

Introduction sagittal approach, involving anterior perineal dissection


Anorectal malformations consist of a wide spectrum of (from the base of the scrotum to the posterior part of the
diseases, which can affect boys and girls, that involve the anoderm), is used by some surgeons, with the aim of
distal anus and rectum as well as the urinary and genital preserving the internal anal sphincter [3].
tracts. They occur in approximately one of the 5000 live
The aim of this study was to present our approach on
births [1].
fistulectomy and anoplasty.
Defects range from very minor defects, which are easily
treated with an excellent functional prognosis, to defects Patients and methods
that are complex, difficult to manage, often associated with This study included 35 neonates who were treated at the
other anomalies, and have a poor functional prognosis. Assuit University Hospital. Their age ranged from 1 to 4
days, and all of them were full term except one who was
Perineal fistulas in both male and female patients have preterm. All of them were diagnosed on a clinical basis to
traditionally been called ‘low’ defects. In these cases, the have low imperforate anus with anoperineal fistula. None
rectum opens in a small orifice, usually stenotic and had major associated anomalies. All the patients under-
located anterior to the center of the sphincter. Most of went complete physical examination, abdominal sonogra-
these patients have excellent sphincter mechanisms and phy, and blood chemistry.
a normal sacrum. In male patients, the perineum may
exhibit other features that help in recognition of this Operative technique
defect, such as a prominent midline skin bridge (known The operation was performed under general anesthesia
as ‘bucket handle’) or a subepithelial midline raphe with the patient in the lithotomy position. A semicircular
fistula that looks like a black ribbon because it is full of incision was made around the fistulous opening; the
meconium. These features are externally visible and help fistulous tract was dissected posteriorly by a fine pair of
diagnose a perineal fistula [2]. scissors or a scalpel till the site of the anus was reached
The anoperineal fistula could be treated by several (Figs. 1b and 2b). The incision was completed on the
approaches. lateral edges of the anal site as an inverted V and the
triangular skin flap was dissected. The rectum was
In the classic cutback procedure, a hemostat is placed in evacuated of meconium. The external sphincter fibers
the anus and the tissue is cut back with cautery exactly in were identified precisely using a nerve stimulator on the
the midline to the posterior border of the external skin. The external sphincter fibers were retracted
sphincter. A simple anoplasty enlarges the stenotic orifice posteriorly, and a posterior midline incision was made in
and relocates the rectal orifice posteriorly within the the rectal pouch to widen the opening (Figs. 2c and 3c).
limits of the sphincter complex. The operation is called The mucosa and anoderm at the cut edges were
a ‘minimal posterior sagittal anoplasty’ [1]. Anterior approximated with absorbable sutures and the triangular

1687-4137
c 2011 Annals of Pediatric Surgery DOI: 10.1097/01.XPS.0000393091.16567.fd

Copyright © Annals of Pediatric Surgery. Unauthorized reproduction of this article is prohibited.


20 Annals of Pediatric Surgery 2011, Vol 7 No 1

Fig. 1

(a) Anoperinel fistula. (b) Excized fistulous tract. (c, d) Postoperative view.

Fig. 2

(a) Anoperinel fistula. (b) Dissection of the tract. (c) Excized tract. (d) Postoperative view.

Copyright © Annals of Pediatric Surgery. Unauthorized reproduction of this article is prohibited.


Fistulectomy and anoplasty for low imperforate anus Ibrahim 21

Fig. 3

(a, a1) Anoperineal fistula (midpenile). (b) Excized tract. (c) Anoplasty. (d) Postoperative view. (e) 15 days postoperative.

skin flap was anastomosed to the incised posterior rectal Continence could be assessed in 23 patients whose
wall to create a partially skin-lined anus (Figs. 1c, 2d and follow-up periods were longer than 3 years using a clinical
3d). The wound was sterilized by povidone iodine and a scoring method, and was scored as ‘good’, ‘fair’, and ‘poor’
small piece of gauze was put in the neoanus. [4]. Twenty-one patients had a good score and two had a
fair score. No patients had a poor score. The incidence of
smearing or staining did not diminish with age. Prolonged
Results management was required in five patients who continued
The operative time ranged from 25 to 40 min. The to have a poor level of fecal continence. Anorectal func-
operation was completed successfully in all patients. All tion was not adversely affected by the anterior position
the patients started gradual oral feeding 2 h postopera- of the anal orifice in most patients after simple perineal
tively and were discharged after 24 to 48 h on oral surgery.
feeding. An oral antibiotic and metronidazole were given
for 4 days.
Discussion
(1) Gradual anal dilation started 2 weeks postoperatively, Anorectal malformations include a wide spectrum of
and continued until the anus became pliable. Period defects in the development of the lowest portion of the
range? intestinal and urogenital tracts. Many children with these
(2) Postoperative stricture occurred in two patients, one malformations are said to have an imperforate anus
responded to dilation and the other needed redo because they have no opening where the anus should
surgery by a simple cutback procedure. be. Perineal fistula is associated with good prognosis,

Copyright © Annals of Pediatric Surgery. Unauthorized reproduction of this article is prohibited.


22 Annals of Pediatric Surgery 2011, Vol 7 No 1

occurs in either sex, and involves a closed anus with a within the limits of the sphincter complex. The
small connection that opens to the perineal body. Some perineal body, the area in which the fistula was
babies with this malformation have a small loop of skin at located, is repaired with a few long-term absorbable
the anal opening that resembles a bucket handle. This is sutures [1]. In our technique, the fistula is dissected
pathognomonic for perineal fistula. Some boys may have up to its connection to the anus; its site is left raw,
no visible perineal opening but may accumulate mucous which heals spontaneously within a few days. The
or meconium in the fistula, which can extend upto the anoplasty is performed as an inverted Y-V technique
median raphe of the scrotum and resemble a black cord without mobilization of the rectum. The external
(meconium) or a string of pearls (mucous) [5]. Meco- sphincter is just retracted posteriorly to allow mobi-
nium is usually not seen at the perineum in a baby lization of the anus and the anoplasty is terminated
with a rectoperineal fistula until at least 16–24 h. Abdo- by a skin-lined posterior quadrant.
minal distension does not develop during the first few
Anorectal malformations have patient outcomes with
hours [2].
greatly improved modern surgical techniques and neona-
The radiologic evaluation of a newborn with imperforate tal care facilities during the last few decades. Early
anus includes an abdominal ultrasound to evaluate survival is a rule today, except in some rare cases with
urologic anomalies. A cross table lateral radiograph can cardiac, urogenital, or chromosomal anomalies that are not
help show the air column in the distal rectum in a small compatible with life. Presently, the overall long-term
percentage of patients for whom clinical evidence does functional outcome expectancy in terms of fecal and
not delineate in 16–24 h [1]. In our study, the perineal urinary continence is relatively optimistic. A majority of
fistulae were easy to diagnose even in the first 6 h, patients reaching adolescence and adulthood are able to
obviating the need for radiography. Abdominal ultrasono- maintain themselves as socially continent [8]. Using the
graphy was carried out as a routine in all cases and there Kelly–Kiesewetter scoring system in 23 patients of our
were no associated renal anomalies in all cases. In one series, 21 had a good score, two had a fair score, and none
case, the fistula reached up to the mid penile position had a poor score [4]. Current mortality rates are low after
and there were no major associated anomalies except in repair of imperforate anus, and most of these deaths are
one patient who had an associated hypospadias. attributable to problems with other organ systems,
particularly the cardiovascular system and central nervous
The decision to perform an anoplasty in the newborn
system. Sepsis (overwhelming infection) is occasionally
period or to delay the repair and to perform a colostomy is
a problem in patients with complicated high anomalies
based on the physical examination of the infant, the
involving the genitourinary system. Mortality in patients
appearance of the perineum, and any changes that occur
was in the range of 5% for low anomalies [9]. In our series,
over the first 24 h of life [6,7].
there were no deaths.
Of our patients, all of them were operated upon within
Our approach has the following advantages: (i) the
the first 24 h except those who presented on the second
operation is simple and easy to perform. (ii) It has a
or the third day; they were operated on the same day of
minimal complication rate, with a good cosmetic and
presentation.
functional outcome. (iii) Anorectal function was not
Low imperforate anus with perineal fistula can be treated adversely affected in patients with anterior position of
by many approaches the anal orifice.
(1) Cutback operation, an anterior sagittal approach,
involving anterior perineal dissection (from the base References
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Copyright © Annals of Pediatric Surgery. Unauthorized reproduction of this article is prohibited.

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