Dr. M.M. Zameer
Consultant Pediatric Laparoscopic and Robotic Surgeon
A preterm girl (33weeks ) was born with an absent anal opening. She had a fistulous opening in the vestibule through which she was passing stool and flatus. She was decompressing well. She was evaluated with USG KUB and ECHO and associated cardiac and renal anomalies were ruled out. She was initially managed with rectal washes. She was tolerating feeds and was not having any constipation. She was discharged on full feeds.
She was planned for definitive surgery (PSARP) at 3 – 4 months of age but the surgery was delayed due to Covid. She underwent PSARP at the age of 11 months. Preoperatively the bowel was well prepared and primary PSARP was done (single surgery without any colostomy). The perioperative period was uneventful. On 3 months follow up, the baby is doing well , tolerating feeds and passing stools (no incontinence).
Feels great to do a PSARP in a child without colostomy (esp in an older child). No surgery / no scar in the abdomen. Only one surgery and the baby is all well.
Vestibular fistula is the most common type of anorectal malformation present in females. The condition is characterised by an abnormal connection between the rectum and the vaginal vestibule with an absent anal opening. It is a intermediate type of Anorectal Malformation (ARM). The feces and the gas exit through the opening in the vestibule.
Babies are diagnosed at birth with an absent anal opening and passage of stools from an opening in the vaginal vestibule. Babies will have different degrees of constipatiion, depending on the size of the fistulous opening. Older babies (esp after the start of weaning) will strain while passing stools.
Some babies have recurrent urinary tract infections. Some babies present with associated cardiac / renal anomalies.
It is diagnosed by clinical examination immediately at birth. There is absent anal opening and a fistulous opening in the vestibule through which the baby passes stools and flatus.
Ultrasound KUB and ECHO have to be done to diagnose associated renal and cardiac anomalies.
PSARP / ASARP is the surgery done to treat this condition. The goal of the surgery is to separate the rectal fistula from the vaginal vestibule and create a neo anus within the anal sphincters. The treatment can be done in 1 , 2 or 3 stages depending on the age of the baby and degree of constipation / intestinal obstruction.
Single Surgery : Primary PSARP is usually done at 3 – 4 months of age. The baby is managed with rectal washes after birth. Single staged surgery can be done in babies without constipation / intestinal obstruction. This is good as the babies don’t have a colostomy and its associated problems.
Two Stages : Here PSARP is done along with colostomy . Colostomy is done in cases where the babies are having constipation at the time of the surgery. The second surgery is colostomy closure which is done after 6 weeks of the first (afetr the bottom wound has healed).
Three Stages : This is done in newborn babies with intestinal obstruction or in children who present late (with severe constipation and dilated bowel). The surgeries done (in the chronological order) are :
Children with vestibular fistula do well . They are fecally continent. They may have mild degree of constipation but this is generally well controlled with diet and medications.