Anorectal malformations

ANORECTAL MALFORMATIONS

د.بسام خالد الحجاراختصاصي جراحة الأطفال

ANORECTAL MALFORMATIONS

- 1 : 4 – 5000 newborns- Males > Females

TYPES OF DEFECTS ( classification )

MALE DEFECTS 1. Low Defects : Perineal fistula Median raphe fistula Bucket handle malformation Anal stenosis Anal membrane 2. Rectourethral bulbar fistula 3. Rectourethral prostatic fistula 4. Rectovesical ( bladder neck ) fistula 5. Imperforate anus without fistula 6. Rectal atresia and stenosis

FEMALE DEFECTS

1. Low defect : Perineal fistula 2. Vestibular fistula 3. Vaginal fistula 4. Imperforate anus without fistula 5. Rectal atresia and stenosis 6. Persistent cloaca

MALE DEFECTS 1. Low Defects : Perineal fistula

Median raphe fistula



2. Rectourethral bulbar fistula

3. Rectourethral prostatic fistula

4. Rectovesical (bladder neck ) fistula

Female Defects

1. Low Defect : Perineal Fistula

2. Vestibular fistula 3 orifices

3. Vaginal Fistula2 orifices

5. Rectal atresia and stenosis

6. Persistent cloaca1 orifice

N.B. Anteriorly displaced anus is a normal anus situated anteriorly

ASSOCIATED DEFECTS
Urogenital - Most common - 20 – 45 % The higher the malformation the higher the incidence Sacrum and Spine Sacrum frequently abnormal deformed reduced in number hemisacrum - Spine frequently shows hemivertebrae

MANAGEMENT

Diagnosis80 – 90 %clinical( fistula ) 10 – 20 %radiological( invertogram ) DO NOTTry to feel rectal pouch Put a needle Low DefectsPerineal Anoplasty( newborn ) OthersColostomy( newborn ) Repair( 3 mo )

INVERTOGRAM OR CROSS TABLE LAT FILM

Wait till abdominal distension occurs( 16 – 24 h )

Measure distance between bowel and skin : < 1 cm = Perineal anoplasty ( newborn )

> 1 cm = Colostomy ( newborn )

N.B. What really matters in the initial diagnosis is whether a particular patient needs a colostomy or not


COLOSTOMY
- Type : sigmoid defunctioning with separate stomas - Site : junction of descending with sigmoid - Incision : left iliac , muscle cutting N.B. Distal loop should be cleared of meconium during operation

DISTAL COLOSTOGRAM

Most valuable test Water soluble contrast into distal stoma Significant pressure needed Under fluoroscopic control Contrast usually fills proximal urethra &bladder Injection must continue till a voiding episode Pictures taken during micturition

Rectourethral bulbar fistula

Started as alternative to laparotomy in cases of rectovesical fistula Now performed in cases of rectoprostatic and rectobulbar fistulae Simpler procedure , easier to perform & less time consuming Results are yet to be evaluated
LAPAROSCOPICALLY ASSISTED ANORECTAL PULL THROUGH

QUESTIONS?????

Q/ A baby boy is delivered in the hospital and found to have an absent anal opening and has meconium appear through fistula in the perineal skin 1. What is the diagnosis(type of defect)? 2. What is the treatment?