ANORECTAL MALFORMATIONS

By Dr. Alberto Pena, MD, VACS, FAAP

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The first important matter that parents must learn about anorectal malformations is that there is a very large spectrum of defects and that each one is different from the other  However, there are certain categories or types of defects with similar prognosis and management.

Neonatal Management

When a baby is born with an anorectal malformation, it is immediately detected as it is a very obvious defect.  Doctors will then determine the type of defect the child was born with and whether or not there are any associate malformations.  As most parents know, children with anorectal malformations are predisposed to suffer from associated defects (mainly urinary tract, as well as spine and sacrum).  It is important to determine the presence of any associated defects during the newborn period in order to treat them early and avoid further sequelae .  There are two main categories of anorectal malformations:  those that require a protective colostomy and those that do not.  The decision to open a colostomy is usually taken within the first 24 hours of life.

No Colostomy*

Under this category are babies who are born with very minimal defects, universally known as "low" malformations.  These patient require a small operation or simply anal dilatations performed during the neonatal period.  The prognosis for bowel control in these children is excellent, and the chances of suffering of an associated malformation are extremely low.  Following the small operation of the anus, these patients still have to be subjected to a protocol of anal dilatations which is usually started two weeks after the operation.

Colostomy

Most patient with anorectal malformations must have a colostomy as a first therapeutic step.  The colostomy is most frequently opened in the left side of the abdomen and is usually made with separated stomas.  This means that the bowel is divided and separated to avoid the passing of stool from one stoma to another.  The purpose of the colostomy is to save the baby's life, to allow decompression of the abdomen by passing stool, and subsequently, the colostomy will serve the purpose of protecting the main repair of the rectum that will be performed in a clean environment without the passage of stool. 

After the colostomy is opened and provided the patient does not have any serious associated malformations, the patients recover very well and go home after a few days.  The parents learn to manage the stoma of the baby.  Within the first month of life the child should grow and develop normally and be ready for the final repair of his/her defect.  Prior to the main operation, it is necessary to perform one more radiological study called Distal Colostogram, which consists of injecting contrast material into the distal stoma (the one that is connected to the rectum) to delineate the characteristics of the specific defect that the baby has, to determine whether the rectum was congenitally communicated with the urinary tract, and to evaluate how the rectum is located in order to plan a strategy to follow during the main operation.

Main Repair

(Posterior Sagittal Anorectoplasty)

The operation used at our institution (Schneider children's Hospital) is called Posterior Sagittal Anorectoplasty.  90% of children's defects can be repaired with this approach, which consists of making an incision between both buttocks while the patient is placed face down on the operating table.  This procedure is usually done when the patient is one month old or older provided he is gaining weight normally.  10% of the patients have a malformation in which the rectum is located very high in the pelvic, and therefore they need an operation through the abdomen to mobilize the rectum in addition to the Posterior Sagittal Anorectoplasty.  These operations usually take between 3 and 5 hours.  Patients stay in the hospital approximately 5 days and will usually need a catheter in the bladder for 5-7 days.

Colostomy Closures

Managing Perineal Skin Care

By Donna C. Wade, R.N., B.S.N., C.E.T.N.

(This article appeared in Sutureline Vol. 3, No. 2, the newsletter of the American Pediatric Nurses' Association [APSNA] and was reprinted by permission of APSNA)

There are currently many products on the market which may play a role in managing perineal skin irritation after an ostomy takedown.  The following is an attempt to list available products.  For mild problems, there are over-the-counter products available at most drug stores that can be used.  These include:

• A & D ointment Balmex cream
  Desitin (zinc oxide) Aquaphor ointment
• Diaperaseptic  Diaper Guard

For moderate or severe breakdown, there are also many commercial options.  Most of these are available through surgical supply stores, ostomy dealers, and some drug stores.  Many of the manufacturers also make no-rinse cleansers which help to dissolve the urine and stool, making clean up easier and less traumatic. Barriers provide more protection than creams.  Some of these products include:

	CREAMS	BARRIERS	CLEANSERS
Sween	Sween Cream Micro-Guard (antifungal)	Baza Cream Peri-Care Critica Aid Paste	Peri-Wash II (no rinse)
Calgon Vestal		Aloe Vesta Protective ointment ILEX ointment	Aloe Vesta Perineal Solution
Vaseline Constant Care	Conditioning Cream	Moisture Barrier Salve	Cleansing Lotion
Smith Nephew	Triple Care Cream	Extra Protective Barrier	Triple Care Incontinent Cleanser
Medline	Soothe & Cool Skin Cream	Soothe & Cool Barrier Cream Inzo Zinc Oxide Barrier	Soothe & Cool Cleanser
Cataline	Special Care Cream Aseptin Skin Cream	Special Care Moisture Barrier Ointment	Biolex Wound Cleanser
Carington		Antifungal Cream & Moisture Barrier Moisture Barrier Cream	Carrafoam Cleanser
Hollister		Restore Barrier Cream	Restore Clean-n-Moist No Rinse Breathable Barrier