All children had postoperative anal dilatations as per the Peña scheme. Data recorded included age, fistula location, associated anomalies, operation performed, operative time, length of hospital stay, approximate cost, and postoperative complications.
Statistical analysis was performed using the Pearson χ2 and Fisher exact tests for nonparametric data and the t-test for equality for parametric data.
Group A included 15 female patients with low ARM: seven patients (47%) had ARM with anocutaneous fistula and eight (53%) showed anovestibular fistula. Their ages at the time of first-stage surgery ranged from 3 months to 11 months (mean age 6.4). Two patients (13%) had assosciated anomalies: one showed an absent kidney and the other had a minor cardiac anomaly. The operative time of this group was calculated for each patient by adding the operative times of both stages; it ranged from 140 to 180 min (mean time 160). The total length of hospital stay for both stages together ranged from 8 to 10 days (mean 8.5). The total approximate cost for both stages for each patient ranged from 1600 to 1800 LE (mean cost 1700).
Group B included 15 female patients with low ARMs: eight (53%) were ARMs with anocutaneous fistula and seven (47%) showed anovestibular fistula. Their ages at the time of surgery ranged from 3 months to 11 months (mean age 6). Two patients (13%) had a minor cardiac anomaly. The operative time of this group was calculated for each patient and ranged from 60 to 120 min (mean time 87). The total length of hospital stay ranged from 5 to 8 days (mean 5.5). The total approximate cost for both stages for each patient ranged from 800 to 1000 LE (mean cost 870).
On comparing the data of both groups, a noticeable variation was found between the two groups: operative time was 160 and 87 min, hospital stay was 8.5 and 5.5 days, and approximate total cost was 1700 and 870 LE, respectively. These data suggest that treatment of patients of group A involved more time and money and they experienced a longer hospital stay compared with group B patients. A statistical significance was found for all three items (Table 1).
Sixteen (53%) patients suffered from 41 postoperative complications: seven (47%) of group A had 17 postoperative complications, whereas nine (60%) of group B had 24 postoperative complications, which indicates that more complications occurred in patients undergoing one-stage PSARP (Table 2).
Wound infection occurred in three patients (20%) of group A and in eight patients (53%) of group B, showing a marked increase in the latter. More importantly, two (13%) patients among the three with wound infections in group A developed wound disruptions; however, they healed conservatively and did not need a redo. The third patient turned out to have anal stenosis, which may not be related to the infection and was managed by regular dilatation. However, six (40%) patients among the eight with wound infections in group B developed wound disruptions (Fig. 5). All of them resulted in a short perineum and three (20%) of these patients developed anal stenosis. The wound disruption in these patients occurred 7–10 days postoperatively and a completely diverting right transverse divided loop colostomy was performed 10–15 days postoperatively when disruption was found to be progressive. They all needed a redo PSARP.
The incidence of redo operation in group B was found to be significantly higher than that in group A in which no redo was needed. Mucosal prolapse occurred in only one patient (7%) of group B and it needed a minimal operation to remedy the condition. Complications related to colostomy occurred in group A only; five patients (33%) suffered skin excoriation around the stoma and one patient (7%) showed a prolapsed distal stoma loop. They were managed conservatively until the stomas were closed.
Constipation was noted during follow-up in five patients (33%) of group A and in six patients (40%) of group B and they were all managed conservatively and responded well.
We believe that the most important decision to be taken for a baby with an ARM is the creation of a colostomy as part of the treatment plan. This is an easy decision if the ARM is intermediate or high; however, the performance of colostomy in low anomalies is a decision disputed by many 14.
Pena 15 insisted at performing a covering colostomy in cases of vestibular fistula. Then, in 1993 he proposed avoiding colostomy in these patients by giving the infants a low-residue diet for 1 week preoperatively and keeping the bowel as empty as possible. In the immediate preoperative period, the colon is thoroughly washed through the fistula to keep the wound as clear as possible in the postoperative period 8.
Low ARMs in girls appear simple but are actually complex anomalies and often underestimated by the treating physician, thus corrected without a covering colostomy or proper preoperative preparation that may result in disruption of the whole repair. The main aim of managing these anomalies is to achieve continence in the child, which remains the real challenge in pediatric surgical practice 1.
In our study we compared two-stage PSARP with colostomy to one stage in girls with low ARMs, aiming to define whether colostomy is of benefit or a setback. Total bowel irrigation was performed for all the patients; nothing per oral and parenteral nutrition were started 1 day preoperatively and continued 2 days postoperatively for all patients. We used this strategy so that group B patients would suffer no disadvantage if patients were prepared by rectal irrigation only.
Our results show that fewer complications occurred in group A than in group B, especially with regard to wound infection and wound disruption; however, no statistical significance was noted. This is because the number of patients is not enough for sufficient statistics. Redo PSARP with a covering colostomy was needed in six patients (40%) of group B who had suffered wound disruptions; however, none of the two patients (13%) with wound disruptions in group A needed a redo as they healed conservatively. This was found to be statistically significant.
Treatment of group B patients involved less time and money and they experienced a shorter hospital stay compared with group A and a statistical significance was found for all three items. They were also spared the complications of colostomy. However, if we consider the fact that six patients (40%) of group B needed a redo two-stage PSARP, we feel that the advantages of one-stage operation are over-rated. We also believe that the complications of colostomy are temporary and tolerable if we can achieve a sound operation and a continent child.
Performing an operation without a colostomy most of the time works as demonstrated by most, but sometimes it does not. If a patient with a perineal fistula has a dehiscence, it is not so relevant; however, for a patient with a vestibular fistula, it is a serious problem, and sometimes it compromises bowel control 16.
We know that the tendency is to perform operations without a colostomy, and we believe that the decision is based on personal experience.
Bowel control in perineal and vestibular fistula patients should be 100%, but they may soil once in a while; most of that soiling is caused by constipation. When you treat the constipation adequately, the soiling disappears, suggesting that they suffer from overflow pseudoincontinence. The patients may experience what is called hidden constipation 17. In our study we had 11 patients (37%) suffering from constipation: five in group A and six in group B, all of whom were managed conservatively and responded well. However, toilet training is a tedious procedure in cases of ARM, even in low types.
Low ARMs in girls are actually complex anomalies that, when corrected without a covering colostomy, may result in disruption of the whole repair. The main aim of managing these anomalies is to achieve continence in the child, which remains the real challenge in pediatric surgical practice. The performance of colostomy in low anomalies is a decision disputed by many but we believe that two-stage repair of low ARMs in girls is truly beneficial, as we could achieve a sound operation and a continent child regardless of complications of colostomy, which are temporary and tolerable.
Conflicts of interest
There are no conflicts of interest.
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