8/14/2019 Perineal Canal PSI 1997 2

1/1

2 8 4Fig . 1 De l in ea t io n o f p e r in ea lcan a l b y f in e Heg a r d i l a to rFig . 2 Dis sec t io n o f r ec tu m f ro mv ag in a a f te r l ay in g o p en f i s tu laFig . 3 Reco n s t ru c t io n o f p e r i -n ea l b o d y an d ex te rn a l an a lsp h in c te r ( s imu l tan eo u s cu tb ackan d p o s te r io r t r an sp o s i t io n o fan te r io r ec to p ic an u s h as b eend o n e )Fig . 4 Po s to p e ra t iv e ap p ea ran ce

p e rs i s ten t v ag in a l d ischa rge , a PC was d i sco v e red wh en sh e wasex amin ed u n d e r an es th es ia fo r a p o ss ib le fo re ig n b o d y. F o u r p a t ien t sh ad an ad d i t io n a l f i s tu lo u s o p en in g ap a r t f ro m th e v es t ib u le (o n th elab ia rn a jo ra an d p e r in eu m in 2 p a t ien t s each ) an d 2 h ad an an te r io rec to p ic an u s . Ou r o ld es t p a t ien t ( ag ed 1 3 y ea r s ) h ad b een o p e ra tedu p o n u n su ccess fu l ly el sewh ere ; sh e p re sen ted w i th recu r ren ce o f th efis tu la and a d ivert ing colostomy.Am o n g th e ma le p a t ien t s , 3 h ad an o p e r in ea l f i s tu lae an d th e 4 th anan o u re th ra l fi s tu la. On e o f th e fo rm er h ad an a s so c ia ted an a l s t en o s i s ,wh i le th e o th e r 3 b o y s h ad an an te r io r ec to p ic an u s . On e fem a le h ad aseptate v ag in a ; th e ma le wi th a n an o u re th ra l f i s tu la h ad a s so c ia tedp ru n e -b e l ly sy n d ro me wi th a fu s i fo rm meg a lo u re th ra .In 5 9 p a t ien t s th e d iag n o s i s was e s tab l i sh ed b y p ro b in g th e f i s tu lawith a f ine Hega r d i la tor (Fig . 1) . The f is tu la orig inated w ith in 1 .5 cmo f th e an a l v e rg e in a l l th e se ca se s . In th e m a le wi th an an o u re th ra lf i s tu la a u re th ro cy s to g ram w as req u i red to co n f i rm th e d iag n o s i s an dd e l in ea te th e an o m a ly .Th e p a t ien t s we re ca teg o r ized in th ree g ro u p s : g ro u p A , wi th o u tany perineal sepsis or excoria t ion (49/60), was treated by primaryan te r io r s ag it t a l an o rec to p la s ty (ASAR P) . Gro u p B , th o se w i th p e r in ea lex co r ia t io n s b u t n o ac t iv e in f lamm at io n (7 /60 ) u n d e rw en t d e lay edASARP a f te r man ag emen t o f th e ex co r ia t io n s . Gro u p C, wi th g ro ssp e r in ea l in f lammat io n o r ab scess fo rma t io n (4 /6 0 ), h ad s tag ed ma n ag e -men t : l ay in g o p en o f th e f i s tu la an d d ra in ag e o f th e ab scesse s wi thperineal reconstruction 12 weeks la ter .S imu l tan eo u s ly wi th th e ASA RR ex c is io n o f th e v ag in a l s ep tu man d u re th ra l p l i ca t io n was d o n e in th e ch i ld w i th a s ep ta te v ag in a . In6 ch i ld ren (1 wi th an a l s t en o s i s an d 5 wi th an te r io r ec to p ie an u s ) , acu tb ack wi th p o s te r io r an a l t r an sp o s i t io n was u n d e r tak en , an d o u ro ld es t p a t ien t u n d e rwen t co lo s to m y c lo sure .

Op e ra t iv e t ech n iq u eOu r t ech n iq u e fo r th e co r rec t io n o f th i s an o ma ly i s th ro u g h an an te r io rsag i t t al app roach, wh ich h as r ecen t ly b een n am ed ASA RP b y O k ad a e ta l . [6] . The patient is kept fas t ing for 4 h before the operat ion; bowelp rep a ra t io n co n s i s t s o f two sa l in e en emas g iv en 8 an d 4 h b e fo resu rg e ry . On e in jec t io n o f a s eco n d -g en e ra t io n cep h a lo sp o r in i s g iv enwi th th e in d u c t io n o f an es th es ia .Th e o p e ra t io n i s p e r fo rmed in th e l i th o to my p o s i t io n . 1 : 1 5 0 .0 0 0ep in ep h r in e so lu t io n i s in f i l t r a ted in to th e t i s su es b e tween th e f i s tu laan d th e an u s w i th a 2 6 -g au g e n eed le . Th e p e r in ea l f i s tu la is l a id o p en inth e mid l in e , ex p o s in g th e ed g e o f th e rec tu m ly in g ad jacen t to th e

v ag in a (Fig . 2 ) . Th e an te r io r wa l l o f th e rec tu m i s d i s sec ted f ro m th ev ag in a u n t i l i t c an b e b ro u g h t d o wn to th e sk in wi th o u t t en s io n an d anan o p la s ty i s p e r fo rmed (Fig . 3 ) . Th e sp h in c te r mu sc le i s n o w su tu reda ro u n d th e an a l c an a l , t ak in g "b i te s " o f th e b o w e l wa l l. T h e p e r in ea lmu sc le s a re su tu red b e tween th e rec tu m an d v ag in a in l ay e r s , r eco n -st i tu t ing the perineal body (Fig . 4) . The skin is then sutured , res ult ingin a n o rm a l - lo o k in g p e r in eu m. Po s te r io r t r an sp o s i t io n o f th e an u s , i fn ecessa ry , c an b e d o n e s imu l tan eo u s ly .Po s to p e ra t iv e ly , th e ch i ld i s a l lo wed o ra l f eed s 4 -6 h a f te r su rge ry.No re s t ra in t i s emp lo y ed , an d u su a l ly n o b lo o d t r an s fu s io n s a rereq u i red . Du r in g co n v a le scen ce th e wo u n d i s k ep t ex p o sed ; th r ice -d a i ly s i t z b a th s an d ap p l ica t io n o f an t ib io t ic o in tmen t p rev en t in fec t io n .In jec tab le an t ib io tic s a re d i sco n t in u ed a f te r 7 2 h . T h e p a t ien t i s u su a l lydischarged on the 5 th postoperat ive day.

ResultsF o r t y - s e v e n o f t he 4 9 g r o u p A p a t i e n t s h a d a s m o o t hp o s t o p e r a t i v e r e c o v e r y w i t h o u t a n y c o m p l i c a t i o n s . O n eh a d r e c u r r e n c e o f t h e f i s t u l a ; t h i s w a s l a i d o p e n a n ds e c o n d a r y r e c o n s t r u c t i o n u n d e r t a k e n a f te r 1 2 w e e k s w i t hu n e v e n t f u l r e co v e r y . T h e 2 r id p a t ie n t ( w i t h p r u n e - b e l l ys y n d r o m e ) d i e d o f u n c o n t r o l l a b l e u r i n a r y s e p s is a n d a z o t e -m i a . A l l 7 g r o u p B p a ti e n ts m a n a g e d b y d e l a y e d A S A R Ph a d u n e v e n t f u l r e c o v e r ie s . T h r e e r e q u i r e d a n a l d i l a t io n s f o r2 w e e k s . T h e 4 g r o u p C p a t i e n ts w h o u n d e r w e n t s e c o n d a r yA S A R P a f t er d r a i n a g e o f p e r i n e a l a b s c e s s e s a l so h a dc o m p l i c a t i o n - f r e e r e c o v e r y , b u t r e q u i r e d a n a l d i l a t i o n s f o r6 w e e k s .

I n 1 7 p a t i e n t s t h e tr a c t s w e r e s u b j e c t e d t o h i s t o l o g i ce x a m i n a t i o n . I n 1 5 t he s e c t i o n s s h o w e d s t ra t i fi e d s q u a m o u se p i t h e l i u m w i t h s u b e p i t h e l i a l i n f l a m m a t o r y c e l l s ; i n 2 t he r ew a s o n l y g r a n u l a t i o n t i ss u e .

F i f t y o f th e p a t i e n t s w e r e s e e n a t f ir s t f o l l o w - u p 1 2 w e e k sa f te r s u r ge r y . A l l w e r e c o n t i n e n t a n d h a d n o r m a l d e f e c a t i o nw i t h o u t t h e u s e o f l a x at i v e s. T h i r t y - f o u r c o u l d b e f o l l o w e db e y o n d t h e a g e o f 3 y ea r s . T h e y w e r e a s s e s s e d f o r c o n -