Project Details

Feasibility of Primary Repair for Anorectal Malformations in Uganda

Felix Oyania, MBChB, MMed

Summary

Abstract BACKGROUND: Most patients in Uganda undergo three separate staged operations: 1) initial colostomy formation; 2) repair of the ARM (called anoplasty), and 3) colostomy closure. Three operations result in long treatment duration, potential complications with each procedure, delays in care, and stigmata associated with ostomies. GAP: Shortening the duration of life with an ostomy to reduce the financial burden, and social rejection, and improve school attendance. HYPOTHESIS: 1: That 1-stage repair, without an ostomy, is safe and effective for children with ARM in Uganda. 2: The ARM scoring guide will allow surgeons to accurately identify children who would benefit from primary anoplasty over a staged repair. 3: A significant reduction in catastrophic healthcare expenditure will occur due to fewer operations and hospital days and no need for ostomy supplies, and children will be more included in the community and able to attend school. METHODS: A retrospective review of 3-stage repair and a prospective partially randomized clinical trial of 1-, 2-, or 3-stage repairs examining complications associated with the treatment of ARM, socioeconomic impact of ARM, morbidity of ostomies, and stigma of ARM-related ostomies. RESULTS: Of the 241 patients included in the analysis – 157 patients had a three-stage repair. A total of 241 patients were included for analysis – 157 patients had a three-stage repair, whereas 84 patients had a one or two-stage repair. 64 (41.3%) were females. We observed that patients who had a 1- or 2-stage repair underwent a Posterior Sagittal Anorectoplasty (PSARP) approach and had their stomas closed at an earlier median age (days) 30.0 (2.0, 150.0). The median (IQR Age at the last surgery (days) was 730.0 (365.0, 1460.0) Vs 180.0 (90.0, 285.0) in 3-stage and 1- or 2-stage repairs respectively. A majority of our patients came from rural settings in both groups 113 (72.9%) Vs 58 (70.7%) in 3-stage and 1-or 2-stage groups (Table 1). There was no difference in post-operative complications compared to patients with a three-stage repair. No complications in 3-stage, 114 (86.4%) and 1- or 2-stage repairs, 69 (82.1%) respectively. Wound Infection (Sacro-Perianal Incision) was 5 (3.8%) in 3-stage repairs and 9 (10.7%) in 1-or 2-stage repairs. (Table 2) Patients who had a two-stage repair had less time with a stoma than those with a three-stage repair. A majority completed their treatment in their first 6 months of life compared with 1-4 years in the 3-stage repairs. (Figure 1) Table 1: Baseline Characteristics 3 Stage Repair 1 or 2 stage repair p-value n = 157 n = 84 Age at diagnosis, median (IQR) 5.0 (2.0, 21.0) 30.0 (2.0, 150.0) 0.034 Age at PSARP in Days, median (IQR) 390.0 (210.0, 1095.0) 150.0 (75.0, 270.0) <0.001 Age at Last Surgery in Days, median (IQR) 730.0 (365.0, 1460.0) 180.0 (90.0, 285.0) <0.001 Percent of Patients with Stoma Closure 128 (84.8%) 84 (100.0%) <0.001 Female 64 (41.3%) 52 (61.9%) 0.002 Residence 0.72 Semi Urban 42 (27.1%) 24 (29.3%) Rural 113 (72.9%) 58 (70.7%)   3 Stage Repair 1 or 2 stage repair p-value n = 157 n = 84 0.28 No Complications 114 (86.4%) 69 (82.1%) Wound Infection (Sacro-Perianal Incision) 5 (3.8%) 9 (10.7%) Anoplasty Breakdown 1 (0.8%) 0 (0.0%) Perineal Body Breakdown 2 (1.5%) 4 (4.8%) Rectal Prolapse 1 (0.8%) 0 (0.0%) Anal Stenosis 2 (1.5%) 1 (1.2%) Peri-anal Skin Excoriation 4 (3.0%) 1 (1.2%) Death 2 (1.5%) 0 (0.0%) Died Following Stoma Closure 1 (0.8%) 0 (0.0%) Table 2: PSARP Complications Figure 1: Length of time with a stoma between 2- and 3-stage repairs. IMPACT: By offering a 1- or 2-stage procedure for ARMs in a resource-limited setting, we expect to: reduce health care expenditure, length of treatment, length of hospital stay, frequency of hospital visits, and social rejection.