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fistulectomy and anoplasty journal

fistulectomy and anoplasty journal

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Fistulectomy and anoplasty in perianal fistula
Fistulectomy and anoplasty in perianal fistula

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Published by: Romberg's sign on Feb 25, 2013
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07/03/2013

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Fistulectomy and anoplasty for low imperforate anus withanoperineal fistula in boys
Ibrahim Ali Ibrahim
Purpose
To present our operative technique for thetreatment of anoperineal fistula, discussing its advantagesin comparison with other methods of treatment.
Patients and methods
This study included 35 neonateboys, 34 were full term and one was preterm. Their ageranged from 1 to 4 days, and they were diagnosed to havelow imperforate anus with anoperineal fistula, withoutassociated major anomalies. They were treated byfistulectomy and anoplasty.
Results
The operative time ranged from 25 to 40min. Theoperation was completed successfully in all patients. Allpatients started gradual oral feeding 2h postoperativelyand were discharged after 24–48h on oral feeding.Postoperative stricture occurred in two patients, oneresponded to dilation and the other needed redo surgeryby a simple cutback technique. Continence could beassessed in 23 patients whose follow-up periods werelonger than 3 years. Twenty-one patients had a good scoreand two had a fair score. No patients had a poor score.
Conclusion
Our approach has the following advantages:(i) the operation is simple and easy to perform. (ii) It hasa minimal complication rate, with a good cosmetic andfunctional outcome. (iii) Anorectal function was notadversely affected in patients with anterior position ofthe anal orifice.
Ann Pediatr Surg 
7:19–22
c
2011 Annals ofPediatric Surgery
Annals of Pediatric Surgery
2011,
7:
19–22
Keywords: anorectal anomalies, anoperineal fistula, low imperforate anus
Department of General Surgery, Pediatric Surgery Unit, Faculty of Medicine,Assiut University, Assiut, EgyptCorrespondence to Ibrahim Ali Ibrahim, Department of General Surgery, PediatricSurgery Unit, Faculty of Medicine, Assiut University, Assiut, EgyptTel: +00 20 105801291; fax: +00 20 882414381
Received
10 May 2010
Accepted
15 June 2010
Introduction
 Anorectal malformations consist of a wide spectrum of diseases, which can affect boys and girls, that involve thedistal anus and rectum as well as the urinary and genitaltracts. They occur in approximately one of the 5000 livebirths [1].Defects range from very minor defects, which are easily treated with an excellent functional prognosis, to defectsthat are complex, difficult to manage, often associated withother anomalies, and have a poor functional prognosis.Perineal fistulas in both male and female patients havetraditionally been called ‘low’ defects. In these cases, therectum opens in a small orifice, usually stenotic andlocated anterior to the center of the sphincter. Most of these patients have excellent sphincter mechanisms anda normal sacrum. In male patients, the perineum may exhibit other features that help in recognition of thisdefect, such as a prominent midline skin bridge (knownas ‘bucket handle’) or a subepithelial midline raphefistula that looks like a black ribbon because it is full of meconium. These features are externally visible and helpdiagnose a perineal fistula [2].The anoperineal fistula could be treated by severalapproaches.In the classic cutback procedure, a hemostat is placed inthe anus and the tissue is cut back with cautery exactly inthe midline to the posterior border of the externalsphincter. A simple anoplasty enlarges the stenotic orificeand relocates the rectal orifice posteriorly within thelimits of the sphincter complex. The operation is calleda ‘minimal posterior sagittal anoplasty[1]. Anteriorsagittal approach, involving anterior perineal dissection(from the base of the scrotum to the posterior part of theanoderm), is used by some surgeons, with the aim of preserving the internal anal sphincter [3].The aim of this study was to present our approach onfistulectomy and anoplasty.
Patients and methods
This study included 35 neonates who were treated at the Assuit University Hospital. Their age ranged from 1 to 4days, and all of them were full term except one who waspreterm. All of them were diagnosed on a clinical basis tohave low imperforate anus with anoperineal fistula. Nonehad major associated anomalies. All the patients under-went complete physical examination, abdominal sonogra-phy, and blood chemistry.
Operative technique
The operation was performed under general anesthesiawith the patient in the lithotomy position. A semicircularincision was made around the fistulous opening; thefistulous tract was dissected posteriorly by a fine pair of scissors or a scalpel till the site of the anus was reached(Figs. 1b and 2b). The incision was completed on thelateral edges of the anal site as an inverted V and thetriangular skin flap was dissected. The rectum wasevacuated of meconium. The external sphincter fiberswere identified precisely using a nerve stimulator on theskin. The external sphincter fibers were retractedposteriorly, and a posterior midline incision was made inthe rectal pouch to widen the opening (Figs. 2c and 3c).The mucosa and anoderm at the cut edges wereapproximated with absorbable sutures and the triangular
Original article 19
1687-4137
c2011 Annals of Pediatric Surgery DOI: 10.1097/01.XPS.0000393091.16567.fd
Copyright © Annals of Pediatric Surgery. Unauthorized reproduction of this article is prohibited.
 
Fig. 1
(a) Anoperinel fistula. (b) Excized fistulous tract. (c, d) Postoperative view.
Fig. 2
(a) Anoperinel fistula. (b) Dissection of the tract. (c) Excized tract. (d) Postoperative view.20
Annals of Pediatric Surgery
2011, Vol 7 No 1
Copyright © Annals of Pediatric Surgery. Unauthorized reproduction of this article is prohibited.
 
skin flap was anastomosed to the incised posterior rectalwall to create a partially skin-lined anus (Figs. 1c, 2d and3d). The wound was sterilized by povidone iodine and asmall piece of gauze was put in the neoanus.
Results
The operative time ranged from 25 to 40min. Theoperation was completed successfully in all patients. Allthe patients started gradual oral feeding 2h postopera-tively and were discharged after 24 to 48h on oralfeeding. An oral antibiotic and metronidazole were givenfor 4 days.(1) Gradual anal dilation started 2 weeks postoperatively,and continued until the anus became pliable. Periodrange?(2) Postoperative stricture occurred in two patients, oneresponded to dilation and the other needed redosurgery by a simple cutback procedure.Continence could be assessed in 23 patients whosefollow-up periods were longer than 3 years using a clinicalscoring method, and was scored as ‘good’, ‘fair’, and ‘poor’[4]. Twenty-one patients had a good score and two had afair score. No patients had a poor score. The incidence of smearing or staining did not diminish with age. Prolongedmanagement was required in five patients who continuedto have a poor level of fecal continence. Anorectal func-tion was not adversely affected by the anterior positionof the anal orifice in most patients after simple perinealsurgery.
Discussion
 Anorectal malformations include a wide spectrum of defects in the development of the lowest portion of theintestinal and urogenital tracts. Many children with thesemalformations are said to have an imperforate anusbecause they have no opening where the anus shouldbe. Perineal fistula is associated with good prognosis,
Fig. 3
(a, a1) Anoperineal fistula (midpenile). (b) Excized tract. (c) Anoplasty. (d) Postoperative view. (e) 15 days postoperative.
Fistulectomy and anoplasty for low imperforate anus
Ibrahim 21
Copyright © Annals of Pediatric Surgery. Unauthorized reproduction of this article is prohibited.

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