Transanal endoscopic-assisted proctoplasty--a novel surgical approach for individual management of patients with imperforate anus without fistula.
OBJECTIVE
Imperforate anus without fistula consists of a spectrum of defects with variable distance between the rectal pouch and the perineum. We have developed a novel surgical approach for individual management of these patients based on precise knowledge of the level of the anomaly.


METHODS
All consecutive patients with imperforate anus without fistula between 2002 and 2004 had sigmoidostomy performed after having failed to pass meconium in the first 24 hours. The upper pouch was intraluminally visualized using retrograde endoscopy through the sigmoid mucous fistula. The distal termination of the rectum was clearly identified as by convergence of the anal columns. Bright translumination of the endoscope light from the rectum to the anal dimple within the external sphincter indicated a low malformation amenable to transanal proctoplasty. The rectum was incised from below under endoscopic visual control. Poor translumination indicated a higher defect, in which case, the operation was converted to standard posterior sagittal anorectoplasty.


RESULTS
Seven patients (6 boys) were identified. Four patients (3 boys) completed transanal endoscopic-assisted proctoplasty. In all cases, the convergence of anal columns indicating rectal termination was right above the anal pit at the site of the maximal external sphincter squeeze. In 3 patients, the operation was converted to posterior sagittal anorectoplasty after verification of a higher anomaly by endoscopy. There were no operative complications. The median follow-up was 3 months (range, 1-26 months). All patients have an appropriate size anus and regular bowel actions.


CONCLUSIONS
Transanal endoscopic-assisted proctoplasty allows safe and anatomical reconstruction of the anorectum, as well as contemporaneous closure of the sigmoidostomy in a significant proportion of patients with imperforate anus without fistula, avoiding the potential complications associated with the open posterior sagittal approach.
Children's Hospital, Section of Pediatric Surgery, University of Helsinki, Stenbäckinkatu 11 PoBox 281, 00029-HUS, Helsinki, Finland. mikko.pakarinen@hus.fi
Mikko P
MP
Pakarinen
Colin
C
Baillie
Antti
A
Koivusalo
Risto J
RJ
Rintala
D001003:Anal Canal; D001006:Anus, Imperforate / Q000601:surgery*; D003663:Decision Trees; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D011351:Proctoscopy / Q000379:methods