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Rectal prolapse following posterior sagittal anorectoplasty for anorectal malformations
Avraham Belizon1, Marc Levitt, Gideon Shoshany
1North Shore-Long Island Jewish Medical Center, Schneider Children's Hospital, New Hyde Park, NY 11040, USA.
Insights
Rectal prolapse after posterior sagittal anorectoplasty (PSARP) in children with anorectal malformations is uncommon (3.8%). Higher defect complexity, poor muscle quality, and vertebral anomalies increase prolapse risk.
Area of Science:
- Pediatric Surgery
- Colorectal Surgery
- Congenital Anomalies
Background:
- Rectal prolapse is a recognized complication in children with anorectal malformations.
- The posterior sagittal anorectoplasty (PSARP) is a common surgical approach for these conditions.
Purpose of the Study:
- To determine the incidence of significant rectal prolapse (>5 mm) post-PSARP.
- To identify objective predisposing factors for rectal prolapse.
- To provide recommendations for prevention and surgical management.
Main Methods:
- Retrospective review of 833 patients with anorectal malformations who underwent primary PSARP.
- Analysis of factors including type of malformation, sacral status, muscle quality, vertebral anomalies, and constipation.
- Evaluation of prolapse incidence and outcomes after surgical repair.
Main Results:
- The incidence of significant rectal prolapse was 3.8% (45/833 patients).
- Higher rates of prolapse were observed in patients with cloaca (6.2%), rectobladder neck fistula (6.8%), and rectourethral fistula (5.4%).
- Low muscle quality and vertebral anomalies significantly increased prolapse risk (20% vs 3.2%).
Conclusions:
- Significant rectal prolapse following PSARP is infrequent.
- Key technical aspects of PSARP may contribute to prolapse prevention.
- Higher anorectal malformations, poorer muscle quality, and vertebral anomalies are risk factors.
- Constipation appears to be a contributing factor to prolapse development.
Purpose:
Rectal prolapse is a known postoperative problem in children with anorectal malformations. The aims of this study were to determine the incidence of significant rectal prolapse (>5 mm), to objectively quantify its predisposing factors, and to offer recommendations as to its prevention and surgical treatment.
Methods:
The authors reviewed their series of 1619 patients with anorectal malformations; 1169 underwent primary posterior sagittal anorectoplasty (PSARP) at their institution between 1980 and 2002, and complete records were available for 833. The series was analyzed for incidence of prolapse, type of anorectal malformation, status of the sacrum, muscle quality, associated vertebral and spinal anomalies, and postoperative constipation. A specific technique for prolapse repair was used.
Results:
Of 833 patients, 45 developed significant rectal prolapse (3.8%). The mean age at the time of PSARP was 0.73 years (range, 0.19-5 years). The average time to recognition of prolapse following PSARP was 13.1 months. Of these 45 patients, 32 required surgical repair and of those, 3 required a second surgical repair. The incidence of prolapse varied by complexity of anorectal defect: cloaca (6.2%), rectobladder neck fistula (6.8%), rectourethral fistula (5.4%), rectovestibular fistula (1.2%), rectal atresia (0%), and rectoperineal fistula (0%). There was a significantly increased incidence of prolapse in patients with a low muscle quality score and in patients with vertebral anomalies (20% vs 3.2%). The presence of a tethered cord and an abnormal sacral ratio did not correlate with an increased incidence of prolapse. Twenty-two patients developed prolapse following colostomy closure, and of these, 12 (55%) suffered from constipation.
Conclusions:
The overall incidence of significant rectal prolapse following PSARP is low. Prevention of prolapse with the PSARP technique may be because of key technical steps. Patients with higher anorectal malformations, poorer muscle quality, and vertebral anomalies had a greater risk of developing postoperative rectal prolapse. The presence of tethered cord and quality of the sacrum were not predictive of postoperative prolapse. Constipation seems to be a factor in the development of prolapse.
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