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Laparoscopic Technique in the Management of High Anorectal Malformations: A Propensity Score-Matched Outcome Study
Jun Tashiro1, Juan E Sola1, Chad M Thorson1
1Division of Pediatric Surgery, DeWitt-Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida.
Insights
Laparoscopically assisted anorectal pull-through (LAARP) offers a shorter hospital stay and lower costs for high anorectal malformations compared to traditional posterior sagittal anorectoplasty (PSARP). Safety and reoperation rates remain similar between the two surgical approaches.
Area of Science:
- Pediatric Surgery
- Minimally Invasive Surgery
- Anorectal Malformations Treatment
Background:
- Posterior sagittal anorectoplasty (PSARP) is the established standard for high anorectal malformations (ARMs).
- Laparoscopic techniques are increasingly utilized in pediatric surgical management.
- Evaluating novel approaches against established standards is crucial for improving patient outcomes and resource utilization.
Purpose of the Study:
- To compare the outcomes of laparoscopically assisted anorectal pull-through (LAARP) versus PSARP for high ARMs.
- To assess differences in length of stay, reoperation rates, complications, and costs between LAARP and PSARP.
- To evaluate the feasibility and impact of adopting minimally invasive techniques in ARM management.
Main Methods:
- Analysis of the Kids' Inpatient Database (1997-2012) for patients with high ARM (ICD-9-CM 751.2).
- Exclusion of patients with perineal fistulas and low/intermediate ARMs.
- Propensity score-matched analysis comparing LAARP (n=178) and PSARP (n=7428) using 37 variables to control for confounding factors.
Main Results:
- LAARP demonstrated a significantly shorter median length of stay (4 days) compared to PSARP (6 days) (P=.003).
- Rates of reoperation, wound infection, wound dehiscence, and mortality were comparable between both surgical approaches.
- LAARP resulted in significantly lower costs ($47,969) compared to PSARP ($56,110) (P=.002), with no significant difference in total charges.
Conclusions:
- Laparoscopically assisted anorectal pull-through (LAARP) is a safe and cost-effective alternative to PSARP for high ARM.
- The minimally invasive approach leads to reduced length of stay and lower hospitalization costs.
- Further research is warranted to establish LAARP as a potential standard technique for ARM management in the coming decade.
Abstract:
Posterior sagittal anorectoplasty (PSARP) has been the standard for management of children with high anorectal malformations (ARMs). Recently, there has been an increase in the use of laparoscopy in its management. We analyzed the outcomes of laparoscopically assisted anorectal pull-through (LAARP) compared to PSARP using a large inpatient database. Kids' Inpatient Database was analyzed for ARM (ICD-9-CM 751.2) between 1997 and 2012. Perineal fistulas and low/intermediate ARM were excluded. Propensity score (PS)-matched analyses were performed using 37 variables. Cases were weighted to provide national estimates. Of the overall 29,106 cases, 7428 patients <2 years underwent surgical repair. LAARP was performed in 178 patients. Eighty-eight percent were male. Most were of Caucasian (n = 71; 45%), followed by Hispanic (n = 41; 26%) descent. Most were performed in 2009 and 2012 (n = 149; 83%). Most were covered by Medicaid (88; 49%), followed by private insurance (80; 45%). Median length of stay (LOS) was 4 (interquartile range = 3) days. The majority were performed in a children's hospital (n = 90; 88%). On PS-matched analysis, LAARP had shorter median LOS (4 [3]) compared to PSARP (6 [15]) days, P = .003. Rates of reoperation, wound infection, wound dehiscence, and mortality were unchanged between approaches. Cost was lower for LAARP (47,969 [49,450]) versus PSARP (56,110 [160,314]) U.S. dollar , P = .002, whereas total charges did not differ significantly. A minimal access approach to a complex procedure requires significant time and resources to be adopted as standard. PSARP is an important example, as increased availability of laparoscopy, and therefore, access to the procedure for patients will greatly affect resource utilization and recovery for the patient. As demonstrated, the LOS and cost is significantly lower for the LAARP procedure in comparison to the traditional approach. Future research will clarify boundaries to introducing the laparoscopic approach as a potential standard technique in the next decade.
