title: A comparison of laparoscopic-assisted (LAARP) and posterior sagittal (PSARP) anorectoplasty in the outcome of intermediate and high anorectal malformations.
abstract: BACKGROUND
  Laparoscopic-assisted ano-rectoplasty (LAARP) has gained popularity since its introduction in 2000. Further evidence is needed to compare its outcome with the gold standard of posterior sagittal ano-rectoplasty (PSARP).
  
  
  METHODS
  A retrospective review of patients presenting with ano-rectal malformation (ARM) in the period 2000 - 2009. Demographics, associated abnormalities, and operative and post-operative complications were assessed. The functional outcome in children older than 3 years was assessed, applying the Krickenbeck scoring system and, where possible, by interviewing parents. Patients with cloacal abnormalities were excluded. Patients with a LAARP were compared with those managed by PSARP.
  
  
  RESULTS
  Seventy-three patients with ARM were identified during the study period. Male to female ratio was 1.6:1. All 32 low ARMs (perineal and vestibular fistulae) were excluded. Thirty-nine had levator or supra-levator lesions. Twenty males presented with recto-bulbar, 3 with recto-prostatic, and 1 with a recto-vesical fistula; 2 had no fistula; and in 2 the data were insufficient to determine the level. Among the females, 6 had recto-vaginal fistulae, 4 had cloacas and 1 had an ARM without fistula. There were 3 syndromic ARMs (2 Trisomy 21 and 1 Baller-Gerald syndrome). One neonate with a long-gap oesophageal atresia had a successful primary LAARP. Seventy-five per cent of all patients had VACTERL associations. Two early deaths after colostomy formation were related to a cardiac anomaly and an oesophageal atresia. In both groups, mean age at anoplasty was 8 months. Twenty of the intermediate/high lesions were treated with LAARP, and 19 by PSARP. There were slightly more complications in the LAARP group; intra-operative injury to the vas deferens and urethra occurred once each. Post-operatively, 2 port-site hernias and 1 case of pelvic sepsis occurred. A poorly sited colostomy caused difficulty in 2 patients. Two patients were converted to laparatomy: severe adhesions in one and a poorly sited stoma in another. Five patients required redo-anoplasty for mucosal prolapse, anal stenosis, incorrect placement of the anus, retraction of the rectum and an ischaemic rectal stricture. Complications in the PSARP group included 2 wound dehiscences, 1 anal stenosis, 3 mucosal prolapses, 1 recurrent fistula and 2 incorrect anal placements requiring redo surgery. The Krickenbeck questionnaire was used in 70% of PSARPs (mean age 5.9 years) and LAARPs (mean age 5.5 years) for a functional assessment. Both groups showed voluntary bowel movements in 14%. Soiling and overflow incontinence was a significant problem. Grade III constipation was less common in the LAARP (14%) than PSARP (21%) group. Four patients in the LAARP group were reliant on regular rectal washouts compared, with 6 in the PSARP group.
  
  
  CONCLUSIONS
  Both LAARP and PSARP can successfully treat ARM but have specific associated problems.
authors.affiliation: Division of Paediatrics Surgery, Stellenbosch University, Tugersberg, W Cape.
authors.forename: C
authors.initials: C
authors.lastname: De Vos
authors.forename: M
authors.initials: M
authors.lastname: Arnold
authors.forename: D
authors.initials: D
authors.lastname: Sidler
authors.forename: S W
authors.initials: SW
authors.lastname: Moore
mesh_terms: D000071056:Anorectal Malformations; D001006:Anus, Imperforate / Q000601:surgery*; D002988:Cloaca / Q000002:abnormalities; D013505:Digestive System Surgical Procedures / Q000379:methods*; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D011183:Postoperative Complications / Q000453:epidemiology; D012006:Rectovaginal Fistula / Q000601:surgery; D014522:Urethral Diseases / Q000601:surgery; D014548:Urinary Fistula / Q000601:surgery