Atresia Ani (Anus Imperforatus) and Management

Atresia Ani

           Congenital atresia ani is quite often need to know doctors and other health personnel in the second birth of a second crew so do not be late in their handling. Anus congenital abnormalities caused by impaired growth, fusion and formation of protrusions embryogenic anus. On congenital abnormalities generally no abnormalities anus rectum, sphincter and pelvic floor muscles. However, the anal agenesis, the internal sphincter may be inadequate.

            Congenital abnormalities of the rectum due to a disruption cloacal separation into rectum and urogenital sinus that is usually accompanied by developmental disorders urorektal septum that separates them. In case this happens fistula between the urinary and genital tract.

Atresia ani (imperforate anus)

            Management of atresia ani in accordance with the location of the end of atresia of the pelvic floor muscles. For the division was made as follows:

      Low lies the atresia ani (translevator)

M through the rectum. Levator anus so that the distance between the skin and the farthest end of the rectum 1 cm. Stenosis can be dilated anus which only requires the anal membrane or a thin membrane which can be opened immediately after child birth. Anus with agenesis of perineal fistula can also be handled immediately after child birth.

      High location of atresia ani (supralevator)

The rectum does not reach m. Levator anus, with the distance between the blind end of the rectum through the perineum skin is more than 1 cm. Usually accompanied by urinary or genital fistula kesaluran.

To determine the class of anorectal malformations used invertogram way. Invertogram capture is a technique to assess the distance of the distal rectal stump to mark the anal skin peritoneum.Baby is placed on techniques upside down (upside down), or sleep terlungkup (prone), with a horizontal beam is directed into the major trohanter. Considered the end of the existing air into the rectum didistal markers anus.

Classification (Wingspread 1981)

Anatomical classification of anorectal malformations:

Male - male

Group I: Action:

1.            Urinary fistula colostomy at the age neonates

2.            Atresia sheath 4-6 months

3.            Flat perineum

4.            Without air fistula> 1 cm from the skin

on invertogr am

Class II: Action:

1.            Perineal fistula surgery without a definitive neonates

2.            Anal membrane kolonostomi

3.            Stenosis ani

4.            Bucket handle

5.            Without fistula, air <1 cm from the skin

on invertogram

Female

Group I: Action:

1.            Cloaca colostomy at the age neonates

2.            Vaginal fistula 4-6 months

3.            Vestibulo fistula ano

4.            Atresia sheath

5.            Without air fistula> 1 cm from the skin

on invertogram

Class II: Action:

1.            Perineal fistula surgery without a definitive neonates

2.            Stenosis ani kolonostomi

3.            Without fistula, air <1 cm from the skin

on invertogram

Picture of disorder anorektum

A.           Anal membranes, 1. direktum air 2. sacral spine

B.           Low lies the atresia ani (perhaps with a fistula of the anterior keperineum)

C.           Atresia ani high position (maybe once a fistula to the urethra or jar - jar)

D.           Atresia rectum. A. direktum air 2. 3 sacral vertebrae. atresia rectum 4. anus

Atresia ani image location high

A.           Rektovesikal fistula, 1.air in the rectum 2.spine 3. bladder 4. simpisis 5. urethra 6. fistula rektovesikal

B.           Fistula rektouretra

Clinical examination

A.           Public inspection

Routine examination remains to be done to look for other abnormalities that 50-60% of patients had congenital abnormalities is elsewhere.

The most commonly found:

v   In the tract genitourinarius 28%

v   Heart defects 74%

v   gastrointestinal tract, eg esofagus9% atresia, duodenal atresia 7%

v   bone abnormalities

B.           Anorectal examination

a.        Women

      Generally 80-90% of women found vaginal fistula or kevestibulum.

Group I

1.            Cloaca

The separation between the urinary tract, genital tract and the digestive tract does not occur. Incomplete evacuation of stool usually so quick to do a colostomy.

2.            Vaginal fistula

Meconium looked out of the vagina, not smooth evacuation of feces. Colostomy should be done quickly.

3.            Vestibule fistula

Vaginal fistula divulva estuary below. Generally smooth evacuation of feces for patients to drink only milk. Evacuation falters when the patient begins to eat solid food. Kolonostomi can be planned if the patient in optimal condition.

4.            Atresia sheath

Disorder in which the anus appear normal, but on digital rectal examination of the finger can not go more than 1-2 cm, so that no evacuation of the stool so it needs to be done colostomy.

5.            Without fistula

Air> 1 cm of skin on invertogram. No evacuation should be done immediately so that a colostomy.

Class II

A.       perineal fistula

There is a hole between the vulva and anus where the normal location. Can be shaped anterior anus, anus appear normal bone, but there are signs diposteriornya tight anus. Generally raises obstipasi.

2.       Stenosis ani

The anal canal is normal location, but very narrow. Smooth evacuation of feces is not definitive surgery should be expedited.

3.       Without fistula

Air> 1 cm of skin on invertogram. No evacuation should be done immediately so that a colostomy.

b.       Male - male

It should be noted that - as follows:

-           Perineum: the shape and the presence of fistula

-           Urine: look for the existence of grain - grain meconium diurin

Group I

A.       fistula urine

Looks meconium out of the urethra orificium eksternum. Fistula can occur keuretra and urinary vesicles.

Practical way to distinguish the location of fistula is by installing a urine catheter.When the catheter is inserted and urine clear, mean fistula located diuretra blocked catheter. When the catheter urine containing meconium, mean urinary fistula kevesika. Evacuation of feces is not smooth and the patient requires immediate colostomy.

2.       atresia sheath

Disorder in which the anus appear normal, but on digital rectal examination of the finger can not go more than 1-2 cm, so that no evacuation of the stool so it needs to be done colostomy.

3.       Perineum flat

Showed that the muscle that serves to kontinensi not fully formed.

4.       Without fistula

Air> 1 cm of skin on invertogram. No evacuation should be done immediately so that a colostomy.

Class II

A.       perineal fistula

Same with women

2.       Membrane anal

Covered with a thin lining of the anus and are visible under the skin of the shadow path meconium. No fecal evacuation. Need an immediate definitive therapy.

3.       Stenosis ani

The anal canal is normal location, but very narrow. Smooth evacuation of feces is not definitive surgery should be expedited.

4.       Bucket handle

The region where normal anus shaped leather covered bucket handle. No fecal evacuation. Need an immediate definitive therapy.

5.       without fistula

Air> 1 cm of skin on invertogram. No evacuation should be done immediately so that a colostomy.

At 10-20% of patients with fistula must be performed radiological examinations invertogram.
 

Management

            Principles of operative treatment of anorectal malformations with the mentioned surgical dissection postero sagittal anorectal posterosagital or plastic. Colostomy is a temporary protection.There are two places recommended colostomy is used in neonates and infants is transversokolostomi (dikolon transverse colostomy) and sigmoidostomi (colostomy disigmoid). Form of colostomy is an easy and safe double-barreled stoma (Double barrel).

Definitive operative technique (Posterior sagittal Ano-recto-plasti)

Principle of operation:

1.            Baby is placed face down

2.            Diperineum incision is made in the midline, from tip to anterior margin markers koksigeus anus.

3.            Still work underlined the middle to prevent nerve damage.

4.            The surgeon must consider the preservation of the entire pelvic floor muscles.

5.            Does not cause trauma to other structures.

Prognosis

1.            With calcification of the above can be evaluated using clinical functions:

a.            Control feces and bowel habits

b.            Rectal sensibility

c.            Strength of muscle contraction on digital rectal sphincter

2.            Psychological evaluation

Continence function not only depends on the strength of the sphincter or sensations, but depends also on the assistance and cooperation of parents and the mental state of patients.

REFERENCES

            Sjamsuhidayat R (2000), Anorektum, Textbook of Surgery, revised edition, EGC,Jakarta, P 901-908.

            Moritz MZ (2003), Operative Pediatric Surgery, Mc. Grow Hill Professional, United State.

Lawrence W (2003), anorectal Anomalies, Current Diagnosis & Treatment, 11th edition, Mc. Graw Hill Professional, United States, the 1324 to 1327.

Reksoprodjo S, anorectal malformation, set of Surgery, Faculty of Medicine, Jakartait 134-139.