You are on page 1of 4

Correspondence to: Dr khalid shreef. lecturer of pediatric surgery.

zagazig university
Tel. 0123855137 0166509297



Annals of Pediatric Surgery
Vol 5, No 3, July 2009, PP 177-180
Original Article

Role of Endoscopic Transillumination in the Diagnosis and Management of
Questionable Cases of Imperforate Anus
Khalid S. Shreef

Pediatric surgery unit, surgery department, Zagazig University, Egypt


Background/ Purpose: ten to twenty percent of cases of imperforate anus are questionable with no clinical evidences
support the diagnosis of the level of the anomaly. The diagnostic tests used to determine the level of defect are not accurate
enough and the surgeon may subject the patient to an unneeded colostomy while the level of the anomaly was low. The aim of
this study is to test the feasibility of using antegrade endoscopic transillumination to give a precise knowledge about the level
of the anomaly in these questionable cases and thus help in the proper management.
Materials & Methods: This is a prospective study comprising ten newborns boys with questionable level of imperforate
anus admitted through the emergency unit of surgery department from May 2007 to April 2009. All Patients had
sigmoidostomy 24-72 hours after having failed to pass the meconium. A pediatric size flexible sigmoidoscope was introduced
through the distal pouch of the sigmoid and the distal termination of the rectum was clearly identified. Bright transperineal
transillumination of the endoscopic light indicated a low malformation amenable to transanal anoplasty with closure of the
sigmoidostomy. Poor or no transillumination indicated a higher defect that needed staged posterior sagittal anorectoplasty.
Results: Ten boys were admitted, Six of them had low anomaly and showed bright transperineal transillumination and were
managed by endoscopic-assisted anoplasty. Four patients had high anomaly with no transperineal transillumination and
their operations were converted to staged posterior sagittal anorectoplasty. There were no operative complications. All
patients with low anomaly (6 patients) were followed regularly in the outpatient clinic; the median follow up period was 6
months. All had a good anal size; four of them had mild to moderate constipation and respond well to medical treatment.
Conclusion: the use of antegrade endoscopic transillumination in questionable cases of imperforate anus helps in reaching
the proper diagnosis, safe identification and reconstruction of the new anus and avoidance of unneeded colostomy in cases
with low anomaly.
Index Word: endoscopic transillumination, imperforate anus.


INTRODUCTION
he diagnosis of anorectal malformations (ARM),
with the exception of anal stenosis, should be
made shortly after birth during the routine neonatal
examination. The vast majority of lesions can be
detected even after the most cursory examination of
the perineum.
1, 2
The initial management of a
newborn baby with ARM depends on the accurate
determination of the exact type and level of the
anomaly (high or low). Eighty to ninety percent of
cases with anorectal anomalies have clinical evidences
that suggest weather the anomaly is high or low. Low
anorectal anomalies are treated simply by anoplasty.
High anomalies are treated in multiple stages
including colostomy, definitive posterior sagittal
anorectoplasty (PSARP), and colostomy closure; or in
a one stage PSARP
3,4
. In 10%-20% of cases, there are
T
Shreef K.

Annals of Pediatric Surgery 178

no clinical evidences suggest the level of the anomaly
and the diagnosis is difficult and questionable, even
after radiological evaluation which have often been
thought inaccurate because of the presence of
meconium in the blind pouch of intestine interfering
with the migration of air into the pouch and giving a
false negative high defect. In questionable cases,
colostomy is the proper management. In 2006, Mikko,
et al used the flexible antegrade sigmoidoscopy in
cases that already had preliminary colostomy by
introducing the sigmoidoscope into the distal colonic
loop to evaluate the level of anomaly before definitive
surgical repair, and reported that many of these cases
had low anomaly and the colostomy was not needed.
5

Based on the idea of Mikko, etal, we suggested a
surgical approach depending on the use of
endoscopic transillumination in native questionable
cases of imperforate anus to give a precise
knowledge about the level of imperforate anus before
creating the colostomy. This approach helps in
diagnosis of the level of anomaly and thus avoids the
unneeded colostomy in cases proved to have low
anomaly.


PATIENTS AND METHODS
A total of ten male patients suffering from
imperforate anus with failure of passage of meconium
for 24-72 hours and had no sings suggesting low or
high anorectal anomalies with questionable cross-
table lateral radiography of the pelvis, were admitted
through the emergency unit of surgical department,
Zaggazig university hospital, Egypt and emergency
unit of surgical department, Edawadmy general
hospital, KSA During the period from May 2007 to
April 2009.
After admission, re-evaluation was done by
meticulous physical examination of the perineum and
external genitalia as well as a search for associated
congenital anomalies including vertebral, cardiac,
tracheal, esophageal and limb anomalies (VACTERL)
was done. As a part of preoperative preparation, the
neonates were given nothing by mouth with insertion
of nasogatric tube, urinary catheter to monitor the
urine output, intravenous fluids were started, and
broad spectrum antibiotics were administrated.
Under general anesthesia, the neonates were put in
supine position. In all patients 2 stay sutures were
taken at the junction between the descending colon
and sigmoid colon, then a small transverse incision

Fig.1 : low imperforate anus with clear transperineal
endoscopic transillumination


Fig.2 : high imperforate anus with absence of transperineal
endoscopic transillumination


(1cm) was made between the stay sutures, followed
by repeated irrigation of the distal pouch using
normal saline with aspiration of the meconium from
the distal pouch. A pediatric size flexible
sigmoidoscope was introduced though the
sigmoidostomy in antegrade direction passing
intraluminally and distally through sigmoid colon.
Once the distal termination of the rectum was clearly
identified by convergence of the anal columns, the
patient's perineum was inspected after turning off the
light of the operating theater. Bright transillumination
of the endoscopic light from the rectum to the anal
dimple indicated a low malformation amenable to
transanal anoplasty (fig. 1). In these cases, an incision
was made in the anal dimple over the center of
Shreef K.
179
Vol .5, No 3, July 2009

perineal transillumination, to reach and open the air-
filled rectum from below under endoscopic visual
control. After gentle dilatation of the anus to an
appropriate size, a full thickness of the rectum was
transanally stitched to the perianal skin and the
operation was completed by removal of the
sigmoidoscope and closure of the sigmoidostomy
incision. Poor or no transillumination through the
perineum indicated a higher defect (fig.2), in these
cases; the sigmoidoscope was removed and the
segmoidostomy incision was converted to a
defunctioning colostomy as a first step for staged
(PSARP) after 4-8 weeks.

RESULTS
Ten newborns boys were subjected to this study, their
ages ranged from 1 to 3 days with a mean age of 1.3
days. Associated anomalies was observed only in one
case in the form of atrial septal defect. All 10 patients
had successful antegrade endoscopy through the
distal part of sigmoid colon and rectum. Six of the 10
patients showed bright transillumination of the
sigmoidoscopy light from the rectal pouch to the
perineum indicating low anorectal malformation, and
these cases successfully underwent anoplasty with
concurrent closure of the sigmoidostomy incision.
Three of the ten patients did not show any
transillumination through the perineal skin, only one
patient showed very dim transillumination, in these
four patients the sigmoidostomy was converted to
traditional defunctioning colostomy. These four
patients were followed, investigated by distal
loopogram and operated after 4-8 weeks using the
posterior sagittal approach and the level of rectal
pouch were observed during operation. Three of
them had high anomaly with fistulae and one had
intermediate anomaly without fistula. There were no
post-operative complications except in one patient
who had prolapsed colostomy. All patients with low
anomaly (6 patients) were followed regularly in the
outpatient clinic; the median follow up period was 6
months. All had a good anal size; four of them had
mild to moderate constipation and respond well to
medical treatment.

DISCUSSION
Newborns with an anorectal malformation without
evidences diagnostic for the level of this anomaly
represent a difficult diagnostic challenge. In 10%-20%
of cases there are no clear evidences about the level of
the anomaly, and the cases are questionable. Prone,
cross table lateral x-ray have often been thought
inaccurate because of the presence of meconium in
the blind pouch of intestine interfering with the
migration of air into the pouch and giving a false
negative high defect.
3,6
Ultrasound evaluation also
has limitations, including the application of too much
pressure at the anal dimple distorting the distance to
the terminal colon and giving a false negative low
defect.
7,8
In questionable cases of imperforate anus
colostomy is the proper solution followed by staged
PSARP after 4- 8 weeks
3
. During definitive repair of
the questionable cases of imperforate anus with
preliminary colostomy Mikko et al, used the
transperineal endoscopic transillumination to detect
the level of anorectal anomaly and reported that
many cases had low anomalies and thus the
distressing colostomy was not needed.
5
We have
suggested the use of transperineal endoscopic
transillumination from the start in questionable cases
of imperforate anus without clear evidences of high
or low anomaly to reach the proper diagnosis and
thus avoid unneeded colostomy. Our results showed
that many questionable cases of imperforate anus are
low (6/10) and were not in need for diverting
colostomy, these results are nearly matches with the
study of Mikko et al
5
. Our approach has many
advantages including: detection of the level of
imperforate anus in questionable case whether low or
high and thus avoidance of unneeded colostomy in
low anomalies with immediate anoplasty; easy and
proper detection of the distal pouch during anoplasty
without extensive perineal dissection by making the
incision directly over the perineal transillumination.
Although the results are encouraging the number of
patients was small and the follow up period was
short to evaluate the long term functional outcome.


CONCLUSION
The use of endoscopic transperineal transillumination
is a safe and useful technique that can be used in
questionable cases of imperforate anus to differentiate
between high and low anomalies, thus avoiding
unneeded colostomy in low anomalies, avoiding the
complications associated with unneeded colostomy
and reducing the time of hospital stay. This
technique also helps in easy identification of the rectal
pouch during anoplasty without extensive perineal
dissection which is very important to preserve the
integrity of perineal muscles and continence.
Shreef K.

Annals of Pediatric Surgery 180

REFERENCES
1. Ameh EA, Chirdan LB .Neonatal intestinal
obstruction in Zaria, Nigeria. East Afr Med J 77:510513,
2000.
2. Archibong AE, Idika IM.Results of treatment in
children with anorectal malformations in Calabar, Nigeria..
S Afr J Surg 42:8890, 2004
3. . Alberto Pena: anorectal anomalies in Robe and
smith's operative surgery, champ and hall 1995 vol.1 pp423-
451
4. Shan zheng, Xianmin Xiao, Yanlei Huang. Single
stage correction of imperforate anus with a rectourethral or
rectovesical fistula by semi-posterior sagittal anorectoplasty.
Pediatr surg Int 24:671-676, 2008
5. Mikko P. Pakarinen, Colin Baillie, Antti Koivusalo,
etal. Transanal endoscopic-assisted proctoplasty-a novel
surgical approach for individual management of patients
with imperforate anus without fistula. J Pediatr Surg 41:314-
317, 2006
6. Berdon WE, Baker DH, Santulli TV, et al. The
radiologic evaluation of imperforate anus. An approach
correlated with current surgical concepts. Radiology 90:466-
71, 1968
7. Oppenheimer DA, Carroll BA, Shochat SJ
Sonography of imperforate anus. Radiology 148:127128,
1983
8. Schuster SR, Teele RL An analysis of ultrasound
scanning as a guide in determination of high or low
imperforate anus. J Pediatr Surg 14:798800, 1979