Malformasi Ano-Rectal

Imperforated anus and Cloacal Malformation:

update on the management

Dr. Hery Poerwosusanta dr, SpB SpBA(K) FICS

Divisi Bedah Anak Departemen Bedah
Fakultas Kedokteran Universitas Lambung Mangkurat/RSUD Ulin
Banjarmasin
• Masalah diseluruh dunia
• Bedah memberikan hasil yang
signifikan
• Operasi I: Amussat 1835
• Cadaver abdominal operation
1953
• Postero Sagital Incision 1980,
Alberto Pena (open pandora
box)
• Globally, 75% of all patients
have voluntary bowel
movements. Half of this group
still soils their underwear
occasionally. Therefore, about
37.5% are considered totally
continent (Pena, 2000)
• Laparoscopic assisted
• 4000-5000/kelahiran hidup
• Laki > perempuan
• 90% diagnosis secara klinik
• Kelainan gen: Down Syndrome
• Terminologi low, intermediate,
high sudah tidak digunakan lagi

Bischoff A et al, 2013

Pena et la, 2000
 Pre NATAL DIAGNOSIS PRE-OPERASI OPERASI POST-OPERASI
• Dilated anal dan calcified • VACTREL SCREENING • During the first 24 h of life • Post operative pain
bowel, lack of meconium • BABY GRAM it is important to rule out • Anal dilatation started 2
at the expected rectal • Spinal-Sacral Ro associated malformations weeks
level. • Spinal Pelvic Ro that might be life- • Perineal rash after
• hydronephrosis, absent • ECHO threatening colostomy was closed
kidney, neural tube • USG • Colostomy (completely • Functional Outcomes
defects, tethered cord, Stabilisasi diverting, leaving enough • Bowel management
hydrocolpos, vertebral • Cairan-Elektrolit distal bowel to allow for program
anomalies, absent radius, • Asam Basa the future pull through), • Toilet training age
and omphalocele a descending colostomy • Treatment of constipation
• Suhu
and hydrocolpos drainage • Bowel Management for
• Faal Hemostasis • High-pressure distal faecal incontinence
• Melakukan klasifikasi colostogram (to • Appendicostomy (Malone
Scaral rasio < 0.4 penanganan determine the specific procedure)
Long common channel > 3cm type of anorectal
malformation in male
patients)
• laparotomy, laparoscopy
or posterior sagittal
approach

Bischoff A, Levitt MA, Peña A. Update on the management of anorectal malformations. Pediatric surgery international. 2013 Sep;29(9):899-904.
Lawal TA. Overview of anorectal malformations in Africa. Frontiers in surgery. 2019 Mar 5;6:7.
Statovci S. Treatment of Children with Anorectal Malformations—10-Year Review. Open Access Library Journal. 2015;2(03):1.
 New born Male infant

No Anus seen at birth 1. Exam of anus determine

size of anoplasty
VACTERL Screening: Babygram, USG
2. Dilatation start 2 weeks
Spinal-Sacral radiograph AP/Lat
post ops old
Urinalysis
3. Follow up:
USG Renal
6 months
Cardiac echo
1 year
R/O esophageal atresia
annually
4. Continence assessment
• Meconium on perineum Inspect PERINEAL @ 24 hours @ 4 year
• Cross table lateral <= 1cm
• Meconium in urine
• Cross table lateral > 1 cm
Primary PSARP Rectum reachable
Stoma, double barrel sigmoidostomy Through posterior PSARP
Sagittal incision
Distal colostogram @ 8-10 weeks
(6 month)
Rectum NOT reachable Laparoscopic assisted
Rentea RM, Levitt MA. Anorectal atresia and cloacal malformations. Holcomb (III) GW, Through posterior Or
Murphy JP, Peter SDSP. eds. Holcomb and Ashcraft's Pediatric Surgery. 7th ed.. Sagittal incision Abdominoperineal
Elsevier. 2020:577-98.
 VACTERL Screening: Babygram, USG Newborn female infant with no visible anus
Spinal-Sacral radiograph AP/Lat
USG Renal
Cardiac echo How many perineal orifices
R/O esophageal atresia
NO UrInalysis
2 1

3 Cloaca
Vaginal Rectovaginal
No Fistula
Atresia fistula
Perineal Vestibular Renal & Pelvis USG
Cross-table
Fistula Fistula
radiograph
Hydrocolpos NO
Expert Hydronephrosis hydrocolpos
Rectum Rectum NOT
only
Reachable through Reachable through
Posterior sagittal Vaginostomy +
Posterior sagittal Colostomy
Primary PSARP Incision Colostomy
Incision
Rentea RM, Levitt MA. Anorectal atresia (<1 cm) (> 1 cm)
and cloacal malformations. Holcomb (III)
GW, Murphy JP, Peter SDSP. eds.
Holcomb and Ashcraft's Pediatric COLOSTOMY 3D Cloacogram + Cystoscopy
Surgery. 7th ed.. Elsevier. 2020:577-98.
• Spinal rasio
• Secara klinik melakukan
pemeriksaan reflek perineum

PEMERIKSAAN SECARA KOMPRIHENSIF

References:
• Rentea RM, Levitt MA. Anorectal atresia and cloacal malformations. Holcomb (III) GW, Murphy JP,
Peter SDSP. eds. Holcomb and Ashcraft's Pediatric Surgery. 7th ed.. Elsevier. 2020:577-98.
• Bischoff A, Levitt MA, Peña A. Update on the management of anorectal malformations. Pediatric
surgery international. 2013 Sep;29(9):899-904
• Peña A, Hong A. Advances in the management of anorectal malformations. The American journal
of surgery. 2000 Nov 1;180(5):370-6.
• Lawal TA. Overview of anorectal malformations in Africa. Frontiers in surgery. 2019 Mar 5;6:7.
• Statovci S. Treatment of Children with Anorectal Malformations—10-Year Review. Open Access
Library Journal. 2015;2(03):1.