Results of reconstructive operations in congenital anocolorectal pathology in children

Abstract

Hirschsprung’s disease (HD) and anorectal malformations (ARM) are among the most common congenital malformations in children with distal gastrointestinal obstruction. Surgical treatment of this pathology is quite complex, in many cases is multi-stage, accompanied by a large number of early and late complications. Despite the development of minimally invasive surgery and the improvement of surgical treatment in recent decades, the functional results of operations do not always satisfy surgeons. In 5-35% of patients there are complications that require long-term treatment, repeated reconstructive surgery, reduce the quality of life of patients.

Purpose - to determine the causes of complications of reconstructive surgery in Hirschsprung’s disease and anorectal malformations in children and to determine the optimal diagnostic and treatment tactics.To determine the causes of complications of reconstructive surgery in Hirschsprung’s disease and anorectal malformations in children and to determine the optimal diagnostic and treatment tactics.

Materials and methods. Survey and analysis of medical records of 70 children aged 1 to 14 years, operated on in the pediatric surgery clinic of IFNMU for HD and ARM during the last 10 years. Among them, 43 children underwent surgery for HG (ratio of girls and boys 1: 5.1) and 27 children for ARM (ratio of girls and boys 1: 1). Among children with HD, the rectosigmoid form was most often observed (22 children), in 10 patients - rectal, in 9 - subtotal, in two - total form. The acute course of the disease was in 11 children, subacute in 12 and chronic in 20 children. Fifteen children (34.9%) had serious preoperative complications that required immediate surgical intervention: intestinal obstruction (11 children), peritonitis (2 children), Hirschsprung-associated enterocolitis (HAEC) in 2 patients.

Among children with ARM, anorectal atresia was most often observed (21 children), 6 of them had supralevator atresia, 15 - infra- or intralevator. One child had anorectal atresia combined with a rare defect - congenital pouch colon, and another had Currarino syndrome. 16 patients had fistula  form of atresia, 5 - without fistula. 4 children had congenital isolated fistulas without atresia (rectovestibular and rectoperineal), and two newborns had severe anorectal stenosis.

Results. The nature of the primary surgery depended on the type of defect and on the presence of preoperative complications. Children with high and intralevator forms of ARM underwent staged surgery: the first stage was colostomy, the second - posterior sagittal anorectoplasty (PSARP) or anterior sagittal anorectoplasty (ASARP), the third - closure of colostomy. The type of stoma depended on the nature of ARM: in the presence of an external wide fistula a terminal sigmostomy was performed (10 patients), in other cases - separated colostomy (7 children). Stoma was applied to 12 children in our own, minimally invasive way. Reconstructive operations were performed at the age of 3-5 months: in 4 children with supralevator forms of atresia PSARP with intra-abdominal mobilization of colon and elimination of fistulas was performed, in 7 patients - PSARP and in 6 children - ASARP.

Children with low forms of ARM (6 patients) underwent primary reconstructive surgery - PSARP or ASARP, four children with congenital isolated fistulas underwent fistula excision.

In 25 (58.1%) children with HD primary reconstructive operations were performed - resection of aganglionic zone with a coloanal anastomosis, in 18 children the first stage of surgical correction was colostomy. Indications for the the stoma imposition were preoperative complications: intestinal obstruction, peritonitis, HAEC, as well as - decompensation of HD and severe metabolic disorders in children. All patients underwent terminal colostomy on the dilated suprastenotic part, except for two children who underwent terminal ileostomy. The following types of reconstructive surgery were used: Soave-Boley surgery with primary anastomosis - 20 patients; transanal endorectal pull throw (TEPT) - 22 children, in 12 children, it was supplemented by minilaparotomy to close the stoma; one child with an ultrashort zone of agangliosis underwent sphincteromyectomy by Lynn.

All operated patients recovered. Early postoperative complications were detected in 4 (14.8%) children with ARM (aghesional intestinal obstruction, postoperative anal stenosis, recanalization of the fistula, discrepancy of the perineal skin sutures - one case for each complication). Among the patients with HD early complications occurred in 10 (23.25%) children: the most common complication was aghesional intestinal obstruction (5 patients), in two children postoperative stenosis of anastomosis developed, HAEC (2 children), failure of colorectal anastomosis (1 child) and an perirectal abscess (1 child).

The study of follow-up and evaluation of long-term functional results of treatment for a period of 6 months to 8 years after surgery in all operated children was carried out. The complete absence of digestive tract disorders was considered as a good result. In cases of unstable disorders that could be corrected conservatively (constipation, flatulence, anal incontinence), the outcome of treatment was considered as satisfactory. Unsatisfactory results were considered in be persistent violations of the transit and closing functions of the anorectal zone and recurrence of obstruction of the digestive tract, which required repeated reconstructive surgery.

In the group of children operated on for HD, good treatment results were observed in 25 (58.1%) patients, satisfactory in 13 children and unsatisfactory in 5 (11.6%) patients. In general, the phenomena of colonic obstruction after surgery, to a greater or lesser degree, were observed in 10 (23.25%) patients, even more often in children there were symptoms of anal incontinence of varying degrees (22 children, 51.2%). HAEC was observed in 5 children. In some patients symptoms of obstruction and incontinence were combined. Repeated reconstructive surgeries were performed in 5 patients, two of them underwent repeated pull throw (in both cases from posterior sagittal access), one patient underwent ileostomy reconstruction, two children underwent anal canal insufficiency correction using our own minimally invasive method. After the interventions in these patients, the impaired functions were completely restored.

Among children operated on for ARM, one child had unsatisfactory treatment result (recanalization of rectovestibular fistula). In 17 (62.9%) patients the results of treatment were good, in the remaining 9 children - satisfactory. Phenomena of colonic obstruction was observed in 4 patients, among them only one child had stenosis of neoanus. 10 patients had symptoms of anal incontinence (8 children had minor smearing, 2 had encopresis). Repeated reconstructive interventions were performed in 4 children: a patient with recurrent fistula underwent surgery in our own way, one child underwent excision of excess rectal mucosa and two children underwent minimally invasive correction of anal canal insufficiency with a volume-forming implant. After operations all the patients recovered.

Thus, in addition to general surgical complications (wound suppuration, anastomotic failure, intestinal obstruction, etc.), the two most common groups of complications of reconstructive surgery in congenital anocolorectal pathology in children were identified: the first group - complications, which are manifested by symptoms of obstruction of anorectal area (stenosis of the colorectal anastomosis, impaired motility of the colon, stenosis of the neoanus), the second - dysfunction of the locking apparatus of rectum (anal incontinence).

Conclusions. A higher frequency of postoperative complications and unsatisfactory treatment results was found after surgical treatment of HD. It is established that the most important risk factors for the development of postoperative complications in HG are the presence of preoperative HAEC, long length of the aganglionic zone, late diagnosis and surgery. The highest frequency of complications in children with ARM was observed in high forms of atresia and in children with concomitant malformations (especially with urinary tract defects). The most common postoperative dysfunction in both groups of children was anal incontinence of varying degrees, but the severity of complications associated with postoperative colon obstruction prevails. Most complications are due to technical and tactical errors during primary surgery. The range of complications largely depends on the method of surgical correction.

The study was conducted in accordance with the principles of the Declaration of Helsinki. Informed consent of parents and children was obtained to conduct the research.

No conflict of interests was declared by the authors.