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Post Operative Anal Dilatations for the Prevention of Anal Strictures in Children With Anorectal Malformation: A
Jessica Taranto1, Isabel C Hageman2, Misel Trajanovska3
1Department of Paediatric Surgery, The Royal Children's Hospital, Melbourne, Victoria, Australia; Surgical Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.
Insights
Routine post operative anal dilatations for anorectal malformations (ARM) may not be universally necessary. Alternative methods show comparable outcomes, suggesting a need for further research to guide evidence-based care.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Anorectal Malformations Management
Background:
- Routine post operative anal dilatations have been standard practice for anorectal malformations (ARM) since 1982.
- Recent evidence questions the necessity and effectiveness of these routine dilatations.
Purpose of the Study:
- To systematically review the literature on the effectiveness of routine post operative dilatations in preventing anal strictures after ARM surgery.
Main Methods:
- A systematic search of major databases (Cochrane, PubMed, Medline, EMBASE) was conducted for English-language articles from 1990 to 2023.
- Included studies focused on children with ARM undergoing reconstructive surgery and subsequent anal dilatations, with anal stricture as the primary outcome.
Main Results:
- Seven studies involving 400 patients were analyzed; 77.7% received routine post operative dilatations (RPD).
- Stricture rates varied widely (0-39% with Peña protocol). Alternative approaches demonstrated similar outcomes (0-22% for daily non-Hegar, 15-18% for weekly surgeon-performed dilatations).
- A single RCT showed comparable stricture rates between dilated (21%) and non-dilated (24%) groups, though study heterogeneity limited direct comparisons.
Conclusions:
- The universal necessity of RPDs for ARM patients may be questionable.
- Alternative post operative care strategies appear to yield comparable outcomes.
- Further large-scale randomized trials are needed to establish evidence-based guidelines for post operative care in ARM.
Background:
Routine post operative anal dilatations have been standard practice in the management of anorectal malformations (ARM) since 1982. Recent studies, however, have questioned their necessity and effectiveness. This systematic review aimed to synthesise the available literature pertaining to the effectiveness of routine post operative dilatations in preventing anal strictures following ARM surgery.
Methods:
A systematic search of Cochrane Library, PubMed, Medline, and EMBASE databases was conducted for English-language articles published between January 1990 and December 2023. Studies reporting on children with ARM who underwent reconstructive surgery, followed by anal dilatations, were included. The primary outcome was the development of anal strictures.
Results:
Seven studies met the inclusion criteria. Of the 400 patients, 311 (77.7 %) patients received routine post operative dilatations (RPD). Stricture rates ranged widely, with the Peña protocol, considered standard practice, resulting in stricture rates between 0 % and 39 %. Alternative approaches showed similar outcomes: daily non-Hegar dilatations (using digital manipulation or candles) resulted in stricture rates of 0-22 %, while weekly dilatations performed by surgeons showed rates of 15-18 %. In the single randomised controlled trial that included a non-dilatation group, comparable stricture rates were observed between patients who received dilatations (21 %) and those who did not (24 %). The heterogeneity in study designs, populations, and outcome measures limited direct comparisons.
Conclusion:
While RPDs have been the standard of care, the available evidence suggests that their universal necessity may be questioned. Alternative approaches appear to achieve comparable outcomes, however the variability in available evidence and lack of large-scale randomised trials both highlight the need for further research to guide evidence-based practice in post operative care for ARM patients.
Level Of Evidence:
Level IV.
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