Original article
Preliminary report on the International Conference for the Development of Standards for the Treatment of Anorectal Malformations

https://doi.org/10.1016/j.jpedsurg.2005.08.002Get rights and content

Abstract

Background

Anorectal malformations (ARM) are common congenital anomalies seen throughout the world. Comparison of outcome data has been hindered because of confusion related to classification and asssessment systems.

Methods

The goals of the Krinkenbeck Conference on ARM was to develop standards for an International Classification of ARM based on a modification of fistula type and adding rare and regional variants, and design a system for comparable follow up studies.

Results

Lesions were classified into major clinical groups based on the fistula location (perineal, recto-urethral, recto-vesical, vestibular), cloacal lesions, those with no fistula and anal stenosis. Rare and regional variants included pouch colon, rectal atresia or stenosis, rectovaginal fistula, H-fistula and others. Groups would be analyzed according to the type of procedure performed stratified for confounding associated conditions such as sacral anomalies and tethered cord. A standard method for postoperative assessment of continence was determined.

Conclusions

A new International diagnostic classification system, operative groupings and a method of postoperative assessment of continence was developed by consensus of a large contingent of participants experienced in the management of patients with ARM. These methods should allow for a common standardization of diagnosis and comparing postoperative results.

Section snippets

International classification of anorectal malformations

The most common previous international classification was referred to as the Wingspread classification of anorectal malformations, elaborated in Wingspread, Wis, in 1984 [1] (Fig. 2). This classification distinguished between high, intermediate, and low anomalies in the male and female, with special groups established for cloacal and rare malformations. High-type anorectal malformations were subdivided into anorectal agenesis with and without fistula, and rectal atresia. The intermediate

International grouping of operative procedures

The Krickenbeck study group decided that, for follow-up studies, not only the site of the fistula should be documented but also an additional grouping according to the operative procedure performed is necessary. The operative procedures are listed in Table 3 as follows: perineal operation, anterior sagittal approach, sacroperineal procedure, PSARP, abdominosacroperineal pull-through, abdominoperineal pull-through, and laparoscopic-assisted pull-through.

International classification for follow-up assessment

After the introduction of the PSARP by Peña [3] and De Vries [4], the major postoperative problem observed was motility disturbances leading to chronic constipation and overflow incontinence, and true sphincter insufficiency with stool incontinence was much less of a problem than was observed in the past [6]. Therefore, after repair, we have to consider 2 different clinical outcomes that must be distinguished from one another to start appropriate therapy: chronic constipation and stool

Conclusions

The participants of the Krickenbeck conference aimed to develop standards for the treatment of anorectal malformations and hope that these 3 new groupings and/or classifications will permit comparison of postoperative results in different centers of pediatric surgery internationally. This will be of great value for children with anorectal agenesis as well as the surgeons that care for them. The final results of the Krickenbeck conference will be published by Springer International Publishers in

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