A full-term newborn boy is found to have a recto-perineal fistula located at the anterior aspect of the sphincter complex seen below, The strategy most likely to reduce the risk for postoperative perineal dehiscence is

[center][/center]

 

 

[size=20px]a Discharge with daily fistula dilations and minimal posterior sagittal anorectoplasty (PSARP) at 6 months of age

 

b Perineal body preserving posterior sagittal anorectoplasty (PPP)

 

c Posterior rectal advancement anoplasty (PRAA) before discharge

 

d End-descending colostomy with minimal posterior sagittal anorectoplasty (PSARP) at 6 months

 

e Minimal posterior sagittal anorectoplasty (PSARP) before discharge[/size]

A

D

D

E

D

C

B

C

Correct answer

c Posterior rectal advancement anoplasty (PRAA) before discharge

 

Rectoperineal fistulas represent 40% of anorectal malformations. Management has evolved over the last five decades from cutback anoplasty to the minimal posterior sagittal anorectoplasty (PSARP), which more reliably places the rectum within the sphincter complex.

 

However, PSARP in these patients may be complicated by perineal body dehiscence or, in boys, urethral injury. The posterior rectal advancement anoplasty (PRAA) avoids dissection anterior to the fistula and leaves no perineal incision. It is appropriate for perineal fistulas that are located in the anterior portion of the sphincter complex, which is nearly always the case in boys.

 

A perineal body preserving posterior sagittal anorectoplasty (PPP) is indicated when a fistula does not lie within the anterior aspect of the sphincter complex (e.g. recto-vesicular and recto-forchette fistulas in girls) and the rectum must be completely mobilized.

 

Either of these procedures may be accomplished safely in a newborn, so staged repair with daily dilations or colonic diversion are usually not needed in the absence of comorbidities like congenital heart disease.

 

Edited August 5, 20251 yr by Admin