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Year : 2012  |  Volume : 1  |  Issue : 2  |  Page : 89-91

Anal transposition (trans-sphincteric ano-rectoplasty) for recto-vestibular fistula

Department of Surgery, King Abdul-Aziz University Hospital, Jeddah 21589, Kingdom of Saudi Arabia

Date of Web Publication13-Sep-2012

Correspondence Address:
Jamal S Kamal
Department of Surgery, King Abdul-Aziz University Hospital, PO Box 80215, Jeddah 21589
Kingdom of Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2278-0521.100959

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Background: Imperforate anus with recto-vestibular fistula is the most common form of imperforate anus in females and is an intermediate type of this disease, which is treated surgically. The current study aimed to compare three techniques used for the treatment of imperforate anus with recto-vestibular fistula. Materials and Methods: Fifty-four cases of imperforate anus with recto-vestibular fistula were managed using three main approaches: posterior sagittal ano-rectoplasty, anterior sagittal ano-rectoplasty, and the anal transposition or trans-sphincteric ano-rectoplasty (TSARP). The functional results and cosmetic appearance for each case after treatment were evaluated in patients above 3 years of age (43 cases). Results: The functional outcomes were good in all treatment groups; however, the better cosmetic results were evident in the group treated using TSARP, a technique, which preserves the skin bridge between the new anus and the posterior fourchette, does not disturb the perineal body, and avoids division of the levator muscles. In this group, a continence rate of 100% but a higher constipation rate (41%) than in the other groups was recorded. Conclusion: TSARP is recommended for imperforate anus with recto-vestibular fistula.

Keywords: Anal transposition, ASARP, PSARP, recto-vestibular fistula, TSARP

How to cite this article:
Kamal JS. Anal transposition (trans-sphincteric ano-rectoplasty) for recto-vestibular fistula. Saudi J Health Sci 2012;1:89-91

How to cite this URL:
Kamal JS. Anal transposition (trans-sphincteric ano-rectoplasty) for recto-vestibular fistula. Saudi J Health Sci [serial online] 2012 [cited 2022 Jan 24];1:89-91. Available from: https://www.saudijhealthsci.org/text.asp?2012/1/2/89/100959

  Introduction Top

Imperforate anus with recto-vestibular fistula is the most common form of imperforate anus in females and is an intermediate type of this disease. [1],[2] In this form, the fistula opens near the vagina at the posterior fourchette and is directed posterior and upward. It is managed surgically by anal transposition, synonymously known as trans-sphincter ano-rectoplasty (TSARP). In this approach, the vestibular fistula is mobilized until completely separated from the vaginal wall, then is transposed within the muscle complex and external sphincter to the site of new anus via a separate incision. [3],[4] This approach was followed until 1982, when PSARP was described and became the accepted method of treatment for various forms of imperforate anus. [5],[6] Contrarily, the ASARP was described in an attempt to avoid the complications of the prone position. [7],[8] Both approaches, PSARP and ASARP, involved division of the levator muscles and muscle complex (the main components of the continence mechanisms), [9] the perineal body, and the perineal skin. This may be associated with wound complications like scar of the perineal skin bridge between the fistula and the new anus [Figure 1] and [Figure 2].
Figure 1: Perineal scar in a patient treated by anterior sagittal ano-rectoplasty

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Figure 2: Partial mucosal prolapse and perineal scar in a patient treated by anterior sagittal ano-rectoplasty

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This complication can be avoided by the TSARP and other techniques like the neutral sagittal anorectoplasty (NSARP) and the trans-fistula ano-rectoplasty (TFARP). [10],[11]

The current study aimed to evaluate the results obtained after treatment of imperforate anus with recto-vestibular fistula by three techniques: TSARP, PSARP, and ASARP.

  Materials and Methods Top

Fifty-four patients with imperforate anus and recto-vestibular fistula were managed at King Abdul-Aziz University Hospital (KAUH) by three techniques. Patients were grouped according to the type of the procedure they had received into Group A (17 patients) by PSARP as previously described, [7] Group B (23 patients) by ASARP, and Group C (14 patients) by TSARP. The mean age at operation was 10.2 months with a range of 2 months to 5 years. Nineteen patients from all groups received a colostomy before their procedure. A few cases were associated with anomalies like tracheoesophageal fistula and esophageal atresia in one case, congenital heart disease in three cases, umbilical hernia in one case, cleft lip and palate in one case, and branchial cyst in one case. Patients above 3 years of age were evaluated for voluntary bowl control, constipation, soiling, mucosal prolapse, a misplaced neo anus, and perineal scarring. The mean age at evaluation was 10.5 years, with a range of 3 to 18 years.

  Results Top

Forty-seven out of 54 cases with imperforate anus and recto-vestibular fistula treated at KAUH were older than 3 years of age and were evaluated [Table 1]. The frequency of each complication was variable among the treatment groups. In the PSARP group, more instances of constipation, mucosal prolapse, and dislocated anus were observed. In contrast, perineal scarring in the ASARP group and constipation in the TSARP group were frequently seen. No correlation was found between the functional results and the performance of a colostomy.
Table 1: Complications arising in imperforate anus with recto-vestibular fistula patients under different treatments

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  Discussion Top

Imperforate anus with recto-vestibular fistula is an intermediate type of this disease in females in which the fistula opens near the vagina at the posterior fourchette and is adherent to the posterior vaginal wall. [12],[13] Patients with this type of anomaly are born with the potential of bowel control, and every effort should therefore be given to perform a successful reconstruction with a single operation. [14] The aim of these procedures was to pull down the rectum and create a new anus within the sphincter. This was done by several approaches like the TSARP in which the vestibular fistula and rectum are mobilized and transposed through the muscle complex to the site of new anus via an incision in the center of the external sphincter as determined by muscle stimulator. In this approach, the muscle complex, the perineal body, and the perineal skin remain intact as previously described. [4],[5]

ASARP is another approach that has been adopted. The ano-rectum is mobilized via a midline vertical incision extending from the fistula to the posterior limit of the external sphincter. The perineal body, the anterior part of the muscle complex, and the perineal skin are divided. [8],[9] From 1982 onwards, PSARP was rapidly adopted for the treatment of various forms of imperforate anus. [6],[7] This approach allowed full visualization of the sphincter complex and clearly showed the relationship of the rectum to the urogenital system and the surrounding structures; however, it involved division of the muscle complex, levators and external sphincter, before the re-joining. [15] Division of the sphincter muscles and the perineal skin in ASARP and PSARP might be associated with problems related to fecal continence and perineal wound complications. [16] In an attempt to improve the outcome, other techniques were described such as NSARP. [11] In this approach, an incision extends from the coccyx to the anterior limit of the external sphincter, identifying the rectum and closing the fistula from its inside, and thereby leaving the perineal skin and levator muscle intact. [11] Another approach is trans-fistula ano-rectoplasty (TFARP) and sphincter-saving ano-rectoplasty (SSARP). [1] This procedure is almost identical to TSARP procedures. [17],[18]

In the current study, constipation was more common in the TSARP group and less so in the PSARP and ASARP cases, where prolapse or dislocated anus and ugly scarring were frequently detected. This could be explained by having an intact sphincter in the TSARP group and divided in the other groups. Mucosal prolapse and mislocated anus could occur as a result of this division as well as technical insufficiency. [19] Although the percentage of constipation in all groups was expected, [20] less than previously reported, [21],[22] it might indicate its disappearance with age [23] and being manageable through a bowel management protocol. [24],[25] However, complications such as prolapsed, perineal scarring, and mislocated anus could be avoided. Otherwise, it requires a secondary intervention, particularly when associated with incontinence. In conclusion, the vestibular fistula was relatively small in number. The results of its management by TSARP were better than with other approaches. The perineal skin remained undisturbed with normal fecal control and a manageable constipation, if it occurred. The TSARP is not a new approach, as it used to be the treatment of this form of anomaly under the name of anal transposition or anal translocation before the introduction of PSARP, and to follow the anatomical type of reconstruction it could be named as TSARP.

  References Top

1.Pena A, Levitt MA. Anorectal Malformations In: Grosfield JL, O'Neil JA, Fonkalsrud EW, Coran AG, editors. Pediatric Surgery. 6 th ed. Philadelphia: Mosby Elsevier; 2006. p. 1566-89  Back to cited text no. 1
2.Donahoe P, Pena A. Abnormalities in the female genital tract. In: Welch, Welch KJ, Randolph JG, Ravitch MM, O'Neill JA, Rowe JMI, editors. Pediatric Surgery. 4 th ed. New York: Year Book Medical Publishers; 1986. p. 1352-62.  Back to cited text no. 2
3.Templeton JM, O'Neil JA. Anorectal malformations. In: Welch, Welch KJ, Randolph JG,Ravitch MM, O'Neill JA, Rowe JMI, editors. Pediatric Surgery. 4 th ed. New York: Year Book Medical Publishers; 1986. p. 1022-34.  Back to cited text no. 3
4.Willital GH. How to avoid complications and continence disturbencies in anorectal malformations. In: Wilital GH, Kiely E, Gohary AM, Gupta DK, Li M, Tsuchida Y, editors. Atlas of children's surgery.Lengerich, Berlin, Bremen, Miami, Riga, Vernheim, Wien, Zagreb:. Pabst Sci 2005. p. 210-23.  Back to cited text no. 4
5.deVries PA, Pen A. Posterior sagittal anorectoplasty. J Pediatr Surg 1982;17:638-43.  Back to cited text no. 5
6.Pena A, Devries PA. Posterior sagittal anorectoplasty: important technical considerations and new applications. J Pediatr Surg 1982;17:796-811.  Back to cited text no. 6
7.oKada A, Kamata S, Imura K, Fukuzawa M , Kubota A, Yagi M, et al. Anterior sagittal anorectoplasty for recto vestibular and anovestibular fistula. J Pediatr Surg 1992;26:85-8.  Back to cited text no. 7
8.Sigalet DL, Laberg JM, Adolph VR, Guttman FM. The anterior sagittal approach for high imperforate anus: a simplification of the Mollard approach. J Pediatr Surg 1996;31:625-9.  Back to cited text no. 8
9.Pena A. Potential anatomical sphincters of anorectal malformations in females. In: Birth Defects; Original article series 1988:163-65.  Back to cited text no. 9
10.Dave S, Shi EC. Perineal skin bridge and levator muscle preservation in neutral sagittal anorectoplasty (NSARP) for vestibular fistula. Pediatr Surg Int 2005;21:711-4  Back to cited text no. 10
11.Partap A, Yadav RP, Shakya VC, Agarwal CS, Singh SN, Sen R. One stage correction of Recto-vestibular fistula by trans fistula anorectoplasty (TFARP). World J Surg 2007;31:1894-7.  Back to cited text no. 11
12.Pena A. Anorectal malformations. In: Ziegler, Aziz Khan, editors. Operative Pediatric Surgery. Gauderer & Weber. New York: McGraw Hill Publisher; 2002. p. 739-62.  Back to cited text no. 12
13.Liu G, yuan J, Geng J, Wang C, Li T. The treatment of high and intermediate anorectal malformations: one stage or three procedures? J Pediatr Surg 2004;39:1466-71.  Back to cited text no. 13
14.Levitt MA, Pena A. Operative management of anomalies in females, In: Holshneider AM, Huston J, editors. Anorectal malformations in children. Berlin: Springer; 2006. p. 303-6.  Back to cited text no. 14
15.Pena A, Levitt MA. Anorectal Anomalies, In: Spitz, Coran, editors. Operative Pediatric Surgery. 6th Ed. London: Hodder Arnold; 2006. p 479-502.  Back to cited text no. 15
16.Sawicka E. Evaluation of late results in the children with anorectal anomalies. Med Wieku Rozwoj 2005;9:695-726.  Back to cited text no. 16
17.Partap A, Tiwari A, Kumar A, Adhikary S, Singh SN, Paudel BH, et al. Sphincter saving anorectoplasty (SSARP) for the reconstruction of Anorectal malformations. BMC Surg 2007;24:7-20.  Back to cited text no. 17
18.Heinen FL. The surgical treatment of low anal defects and vestibular fistulas. Semin Pediatr Surg 1997;6:204-16.  Back to cited text no. 18
19.Belizona A, Levitt MA, Shoshany G, Rodriguez G, Pena A. Rectal prolapse following posterior sagittal anorectoplasty for anorectal malformations. J Pediar Surg 2005;40:192-6.  Back to cited text no. 19
20.Rintala R, Lindahl H, Marttinen E, Sariola H. Constipation is a major functional complication after internal sphincter-saving posterior sagittal anorectoplasty for high and intermediate anorectal malformations. J Pediatr Surg 1993;28:1054-8.  Back to cited text no. 20
21.Pena A. Results of Surgical management of 332 cases of anorectal malformations. Pediatr Surg Int 1988;3:94-104.  Back to cited text no. 21
22.Pena A, Levitt M. Outcome from the correction of anorectal malformations, current opinion. Pediatrics 2005;17:394-401.  Back to cited text no. 22
23.Rintala RJ, Lindahl HG. Fecal continence in patients having undergone posterior sagittal anorectoplasty procedure for a high anorectal malformation improves at adolescence, as constipation disappears. J Pediatr Surg 2001;36:1218-21.  Back to cited text no. 23
24.Levitt Ma, Pena A. Bowel management. In e-medicine, pediatric Surgery, 2004. Available from: http//www.emedicine.com. [Last accessed on 2012 Apr 12].  Back to cited text no. 24
25.Levitt MA, Pena A. Treatment of chronic constipation and resection of the inert rectum. In: Holschneider AM, Hutson J, editors. Anorectal malformations in Children. Heidelberg: Springer; 2006. p. 415-20.  Back to cited text no. 25


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  [Table 1]

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