Assessment of the Heineke–Mikulicz anoplasty for skin level postoperative anal strictures and congenital anal stenosis

doi:10.1016/j.jpedsurg.2018.10.006

Journal of Pediatric Surgery

Volume 54, Issue 1, January 2019, Pages 118-122

https://doi.org/10.1016/j.jpedsurg.2018.10.006 Get rights and content

Abstract

Introduction

Acquired skin-level strictures following posterior sagittal anorectoplasty (PSARP) and some rare cases of congenital anal stenosis can be managed using a Heineke–Mikulicz like anoplasty (HMA). We hypothesized that this procedure was an effective, safe, and durable outpatient procedure in select patients.

Methods

We retrospectively reviewed all patients who underwent HMA for skin level strictures following PSARP or for certain congenital anal stenoses from 2014 to 2017.

Results

Twenty-eight patients (19 males, 9 females) with a mean age of 5.8 years (range 0.5–24.4) underwent HMA. Twenty-six had a prior PSARP, of which 18 were redo, and 8 were primary procedures. Two patients had congenital skin level anal stenosis. The mean follow up was 1.0 years (range 0.4–2.9). The average preprocedure anal size was Hegar 8, which after HMA increased 8 Hegar sizes to 16 (95% CI 7–9, p < 0.001). There were no operative complications. One patient restenosed and required a secondary procedure.

Conclusion

HMA is a safe procedure for skin-level anal strictures following PSARP (primary and redo) and can also be used in some rare cases of congenital anal stenosis. Long-term follow up to determine the restricture rate is ongoing. A plan to do an HMA if a stricture develops may offer an alternative to routine anal dilations, particularly after a redo PSARP in an older child.

Type of study

Case series.

Level of evidence

Level IV.

Section snippets

Methods

We retrospectively reviewed all patients who underwent HMA at our Center for skin level strictures following PSARP or for congenital anal stenosis from 2014 to 2017. It should be noted that it is our current practice to perform routine dilations after our own primary PSARP but not after redo PSARP given that this population of patients is generally older than patients at the time of primary PSARP, and they often have a history of previous traumatic dilation. For patients in whom dilations are

Results

28 patients (19 males, 9 females) underwent HMA over the study period. The mean age at the time of HMA was 5.8 years (range 0.5–24.4). Patients underwent HMA at a mean of 1.9 (range 0.2–13.1) years following PSARP. 25/28 (89%) of patients were symptomatic from their stricture, with all 25 patients presenting with constipation and 9/28 (32%) having one or more episodes of fecal impaction. The remaining 3 patients were diagnosed with a stricture on routine examination after PSARP. 26 had

Discussion

The optimal surgical management of a postoperative stricture after PSARP is not well defined, although a number of techniques exist [10], [13], [14], [15]. We previously reported on the technique of a Heineke–Mikulicz-like anoplasty for the treatment of skin-level strictures [10]. Since the effectiveness and durability of this procedure remain unknown we chose to evaluate the technique further, focusing on its safety and longer term functional outcomes. Our results show that this procedure can

Conclusion

The Heineke–Mikulicz anoplasty is a simple procedure that can be performed in the outpatient setting to treat skin-level anal strictures after primary and redo PSARP and in select cases of congenital anal stenosis. Our results suggest that this procedure has good durability with a low recurrence rate.

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Expertise Area 1.7: Ano-uro-rectal malformations
2024, Rare and Complex Urology
This chapter covers the spectrum of anorectal malformations (ARM) and its present-day classification. This classification aids in comparing data for counselling, research, and benchmark purposes. Recently, Orphanet codes have been introduced, adopting the ARM terminology and providing standardisation of nomenclature. Associated anomalies, mainly urogenital, are covered briefly.
Next, neonatal management is described, explaining what physical signs and diagnostic studies help define the actual ARM type. An algorithm for surgical care introduces the steps needed to provide appropriate care. The different procedures, such as colostomy or primary repair, and the different approaches, such as the posterior sagittal anorectoplasty (PSARP), are described in detail. Surgical key steps are presented, depending on the different ARM types. Follow-up and its key features, such as treatment and prevention of constipation, multi-disciplinary behavioural treatment (MBT), and care of potential sequelae of additional associated anomalies, are included. Finally, outcomes and transition to adult care are discussed.
Nurses' Experiences With Anal Dilatations in Babies With Anorectal Malformations – A Focus Group Interview Study
2023, Journal of Pediatric Surgery
To explore nurses' experiences with anal dilatations in babies with anorectal malformations.
Most babies with anorectal malformations require repeated anal dilatations, either before and/or after reconstructive surgery. Anal dilatation is usually performed without sedation or pain medication. Nurses participate in anal dilatations by assisting doctors doing anal dilatation, doing anal dilatation themselves, and instructing parents how to do anal dilatations. No previous studies have explored how nurses experience being involved in anal dilatations.
Qualitative study design utilizing focus group interviews. The COREQ guidelines were applied.
Nurses with either ≤2 or ≥10 years' working experience participated in two different focus group interviews. The focus group interviews were transcribed and analyzed with content analysis.
Twelve nurses, two males, participated. Three main themes emerged from the focus group interviews. The first main theme, “Anal dilatation causes distress”, describes the nurses' worries about causing physical and/or psychological harm when doing anal dilatations. The second main theme, “Need for guidelines and training”, contains nurses' recommendations for more theoretical training in addition to written guidelines on anal dilatations. The third main theme, “Collegial support is vital”, describes nurses' needs and strategies for coping with difficult situations related to anal dilatations.
Anal dilatation causes distress in nurses, and collegial support is essential for coping. Guidelines and systematic training are recommended to improve current practice.
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Perineal cutaneous appendix and anorectal malformation
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The cutback revisited — The posterior rectal advancement anoplasty for certain anorectal malformations with rectoperineal fistula
2022, Journal of Pediatric Surgery
Citation Excerpt :
Those patients whose perineal fistula opened outside of (and anterior) to the sphincter muscle complex were not considered appropriate candidates for this procedure and underwent PSARP, with fistula and distal rectum mobilization and re-location to the center of the sphincters. Patients whose anal openings were centered within the sphincter complex but had a skin-level stricture were managed with either dilations or a Heineke-Mikulicz anoplasty [6]. All patients were screened for other components of the VACTERL association (renal ultrasound, spine x-ray, and echocardiography) and spinal cord abnormalities (spinal cord ultrasound or MRI) prior to surgical repair.
The repair of rectoperineal fistulae can pose a significant challenge to the pediatric surgeon given the proximity of the fistula to the urethra in males and vagina in females. In these children, a simple cutback procedure may leave the neoanus in a position anterior to the center of the sphincter, which theoretically could impair future continence. We devised an adaptation of the cutback anoplasty which we call the posterior rectal advancement anoplasty (PRAA) to treat patients with a rectoperineal fistula that is both narrow in lumen and located within, but at the anterior-most limit of the sphincter complex.
Patient selection, operative steps, and perioperative care of patients undergoing PRAA are detailed.
10 children (6 males, 4 females) underwent PRAA. There were no vaginal wall or urethral injuries. At 6 months postoperatively, all patients were passing stool spontaneously. No patients required dilation of the anoplasty in the postoperative period and there were no anal strictures identified.
A modification of the cutback anoplasty can be performed in patients with a perineal fistula and the distal fistula tract within the sphincter complex. We have demonstrated that this can be performed safely and obviates the need for an anterior rectal wall dissection, thus eliminating the risk of injury to urethra or vagina.
Level of evidence: IV
Are routine postoperative dilations necessary after primary posterior sagittal anorectoplasty? A randomized controlled trial
2021, Journal of Pediatric Surgery
Citation Excerpt :
HMA offers an excellent solution for strictures involving only the mucocutaneous anastomosis. A study by Halleran et al demonstrated that HMA for strictures, a technique originally described in 2016 [20], is safe with immediate and sustained long term results [21]. During their study period, 28 patients underwent HMA, with an average increase of the neo-anus size from pre-procedural to post-procedural Hegar 8 to Hegar 16 respectively.
: For the past four decades, routine daily postoperative anal dilation by parents has been the standard treatment following a primary posterior sagittal anorectoplasty (PSARP). However, the clinical benefit of this practice has never been formally investigated. It is known that dilations can have a significant negative psychological impact on patients and families, and therefore, we aimed to study if routine dilations after a PSARP are necessary.
: A prospective, single institution randomized controlled clinical trial was conducted on patients with anorectal malformations (ARM) at our institution between 2017 and 2019. Patients were randomized to either a dilation or non-dilation group following their PSARP. Inclusion criteria included age less than 24 months and all patients undergoing primary repair of their ARM (except for cloaca). Patient characteristics, type of ARM, presence of colostomy, postoperative stricture, need for a skin level revision (Heineke-Mikulicz anoplasty (HMA)), and need for redo PSARP were recorded. The primary outcome of the trial was stricture formation. The secondary outcome included strictures requiring interventions. A p-value of less than 0.05 was considered statistically significant. Institutional approval was obtained for this study and informed consents were obtained from all the patients.
: 49 patients were included in our study. 5 (21%) in the dilation group and 8 (32%) in the non-dilation group developed strictures (p=0.21). Of these, 3 (13%) patients in the dilation group required HMA, and 4 (16%) patients in the non-dilation group required HMA (p=0.72). 4 patients required a redo operation for strictures: 2 in the dilation arm (these patients despite the plan to do dilations, chose not to do them consistently) and 2 in the non-dilation arm (p=0.59).
: Routine dilations after PSARP do not significantly reduce stricture formation. Based on these results, non-dilation is a viable alternative, and HM anoplasty remains a good back-up plan if a stricture develops.
: Level I
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Citation Excerpt :
Cicatrization of the muco-cutaneous anastomosis after an anoplasty procedure, or at the anorectal anastomosis in a Hirschsprung pull-through procedure, can lead to devastating outcomes. As previously mentioned, where post-operative follow-up care is expected to be extremely limited, surgeons may elect to create an anoplasty that is wider than the limits of the anal sphincter complex or a Heineke-Mikulicz anal stricturoplasty.1,46,63 Routine serial home dilation of the anastomosis is usually started within 2–4 weeks after the procedure.
Colorectal disease profiles for children in low- and middle-income settings (LMIC) are characterized by late presentation, increased complications and limited follow-up in many cases. There is a high prevalence of infectious conditions causing secondary colorectal disease such as Mycobacterium Tuberculosis(TB), Human Immunodeficiency Virus(HIV) and Human Papilloma Virus(HPV), which also impact the management of other primary colorectal conditions, such as wound-healing and intestinal anastomosis. Perineal trauma from sexual assault, motor vehicle or pedestrian accidents, burns, and traditional enemas are commonly encountered and may require adaptation of principles used in treatment of congenital anomalies such as Hirschsprung's disease and Anorectal Malformations for reconstruction. Endemic conditions in certain LMIC require further research to delineate underlying causes and optimize management, such as “African” degenerative visceral leiomyopathy, congenital pouch colon in the Indian subcontinent, and congenital H-type rectal fistulae prevalent in Asia. These unique disease profiles require creative adaptations of resources within poor healthcare infrastructure settings. These special challenges and pitfalls in colorectal care and complications of adverse socioeconomic conditions, are discussed.

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Author Contribution:

Study conception and design: DRH, AVS, RMR, LW, CR, ACG, MAL, RJW

Acquisition of data: DRH, AVS, RMR, HA, LW

Analysis and interpretation of data: DRH, AVS, RMR, HA, LW, CR, ACG, MAL, RJW

Drafting of manuscript: DRH, AVS, RMR, HA, CR, ACG, MAL, RJW

Critical revision of manuscript: DRH, AVS, RMR, HA, LW, CR, ACG, MAL, RJW

^☆☆: How this paper will improve care: The Heineke–Mikulicz anoplasty is a safe and effective outpatient procedure for the treatment of skin-level strictures after PSARP and select cases of congenital anal stenosis and may provide an alternative treatment to routine dilations after primary PSARP.

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Appendix/ColorectalAssessment of the Heineke–Mikulicz anoplasty for skin level postoperative anal strictures and congenital anal stenosis☆,☆☆

Abstract

Introduction

Methods

Results

Conclusion

Type of study

Level of evidence

Section snippets

Methods

Results

Discussion

Conclusion

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

Urology

Semin Thorac Cardiovasc Surg

J Pediatr Surg

J Pediatr Surg

Am J Surg

Surg Clin North Am

J Pediatr Surg

Appendix/Colorectal
Assessment of the Heineke–Mikulicz anoplasty for skin level postoperative anal strictures and congenital anal stenosis☆,☆☆