Devin R Halleran1, David Coyle2, Afif N Kulaylat3, Hira Ahmad4, Jacob C Langer5, Alessandra C Gasior4, Karen A Diefenbach4, Richard J Wood4, Marc A Levitt6. 1. Department of Surgery, Upstate Medical University, Syracuse, NY, United States. Electronic address: devinrhalleran@gmail.com. 2. Children's Health Ireland at Crumlin, Dublin, Ireland. 3. Division of Pediatric Surgery, Penn State Children's Hospital, Hershey, PA, United States. 4. Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, Columbus, OH, United States. 5. Division of General and Thoracic Surgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Canada. 6. Division of Colorectal and Pelvic Reconstruction, Children's National, Washington DC, United States.
Abstract
BACKGROUND: The repair of rectoperineal fistulae can pose a significant challenge to the pediatric surgeon given the proximity of the fistula to the urethra in males and vagina in females. In these children, a simple cutback procedure may leave the neoanus in a position anterior to the center of the sphincter, which theoretically could impair future continence. We devised an adaptation of the cutback anoplasty which we call the posterior rectal advancement anoplasty (PRAA) to treat patients with a rectoperineal fistula that is both narrow in lumen and located within, but at the anterior-most limit of the sphincter complex. MATERIAL AND METHODS: Patient selection, operative steps, and perioperative care of patients undergoing PRAA are detailed. RESULTS: 10 children (6 males, 4 females) underwent PRAA. There were no vaginal wall or urethral injuries. At 6 months postoperatively, all patients were passing stool spontaneously. No patients required dilation of the anoplasty in the postoperative period and there were no anal strictures identified. CONCLUSIONS: A modification of the cutback anoplasty can be performed in patients with a perineal fistula and the distal fistula tract within the sphincter complex. We have demonstrated that this can be performed safely and obviates the need for an anterior rectal wall dissection, thus eliminating the risk of injury to urethra or vagina. LEVEL OF EVIDENCE: IV.
BACKGROUND: The repair of rectoperineal fistulae can pose a significant challenge to the pediatric surgeon given the proximity of the fistula to the urethra in males and vagina in females. In these children, a simple cutback procedure may leave the neoanus in a position anterior to the center of the sphincter, which theoretically could impair future continence. We devised an adaptation of the cutback anoplasty which we call the posterior rectal advancement anoplasty (PRAA) to treat patients with a rectoperineal fistula that is both narrow in lumen and located within, but at the anterior-most limit of the sphincter complex. MATERIAL AND METHODS: Patient selection, operative steps, and perioperative care of patients undergoing PRAA are detailed. RESULTS: 10 children (6 males, 4 females) underwent PRAA. There were no vaginal wall or urethral injuries. At 6 months postoperatively, all patients were passing stool spontaneously. No patients required dilation of the anoplasty in the postoperative period and there were no anal strictures identified. CONCLUSIONS: A modification of the cutback anoplasty can be performed in patients with a perineal fistula and the distal fistula tract within the sphincter complex. We have demonstrated that this can be performed safely and obviates the need for an anterior rectal wall dissection, thus eliminating the risk of injury to urethra or vagina. LEVEL OF EVIDENCE: IV.
Authors: Eva E Amerstorfer; Eberhard Schmiedeke; Inbal Samuk; Cornelius E J Sloots; Iris A L M van Rooij; Ekkehart Jenetzky; Paola Midrio Journal: Children (Basel) Date: 2022-06-03
Authors: Maria E Knaus; Hira Ahmad; Tran Bourgeois; Daniel G Dajusta; Richard J Wood; Molly E Fuchs Journal: Pediatr Surg Int Date: 2022-08-05 Impact factor: 2.003