Date Published: January 18, 2017
Publisher: Public Library of Science
Author(s): Yijiang Han, Zhaobo Xia, Shikun Guo, Xiangbo Yu, Zhongrong Li, Shian-Ying Sung.
Anorectal malformations (ARMs) are one of the commonest anomalies in neonates. Both laparoscopically assisted anorectal pull-through (LAARP) and posterior sagittal anorectoplasty (PSARP) can be used for the treatment of ARMs. The aim of this systematic review and meta-analysis is to compare these two approaches in terms of intraoperative and postoperative outcomes.
MEDLINE, Embase, Web of Science and the Cochrane Library were searched from 2000 to August 2016. Both randomized and non-randomized studies, assessing LAARP and PSARP in pediatric patients with high/intermediate ARMs, were included. The primary outcome measures were operative time, length of hospital stay and total postoperative complications. The second outcome measures were rectal prolapse, anal stenosis, wound infection/dehiscence, anorectal manometry, Kelly’s clinical score, and Krickenbeck classification. The quality of the randomized and non-randomized studies was assessed using the Cochrane Collaboration’s Risk of Bias tool and Newcastle-Ottawa scale (NOS) respectively. The quality of evidence was assessed by GRADEpro.
From 332 retrieved articles, 1, 1, and 8 of randomized control, prospective and retrospective studies, respectively, met the inclusion criteria. The randomized clinical trial was judged to be of low risk of bias, and the nine cohort studies were of moderate to high quality. 191 and 169 pediatric participants had undergone LAARP and PSARP, respectively. Shorter hospital stays, less wound infection/dehiscence, higher anal canal resting pressure, and a lower incidence of grade 2 or 3 constipation were obtained after LAARP compared with PSARP group values. Besides, the LAARP group had marginally less total postoperative complications. However, the result of operative time was inconclusive; meanwhile, there was no significant difference in rectal prolapse, anal stenosis, anorectal manometry, Kelly’s clinical score and Krickenbeck classification.
For pediatric patients with high/intermediate anorectal malformations, LAARP is a better option compared with PSARP. However, the quality of evidence was very low to moderate.
Anorectal malformations (ARMs), including imperforate anus, occurs in approximately 1 in 4000–5000 liveborn infants . Wingspread classification distinguishes high, intermediate and low ARM types, according to the relationship of the terminal rectum to levator ani . Krickenbeck classification is based on previous experience, stressing the presence and position of fistula, considering bulbar fistulas and imperforate anus without a fistula as well as most vaginal fistulas as intermediate-type anomalies, and prostatic and bladder neck fistulas as high-type imperforate anus . For selecting the surgical approach, the international Wingspread classification remains useful.
The study was adhered to the guidance provided in the Cochrane Handbook for Systematic Reviews of Interventions , and it was reported conforming to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement .
In conclusion, LAARP is a safer, more feasible and effective surgical procedure compared with PSARP in treating high/intermediate anorectal malformations in pediatric patients. LAARP has shorter hospital stay, reduced wound infection/dehiscence, and higher ACRP compared with PSARP. In addition, LAARP has marginally significant advantage of less total postoperative complications. Furthermore, the result of operative time is inconclusive; meanwhile, LAARP and PSARP have similar statuses of rectal prolapse, anal stenosis, anorectal manometry, Kelly’s clinical score, and Krickenbeck classification. However, follow-up may not have been long enough, only one RCT was included, and the quality of evidence was very low to moderate. Long term follow-up, large, multi-center studies, and high quality randomized controlled trials are needed in the future to confirm the current findings.