Effectiveness of primary repair for low anorectal malformations in Uganda
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In brief
In brief
This Ugandan clinical trial demonstrates that primary one- or two-stage repair of low anorectal malformations is as safe as traditional three-stage repair but significantly reduces treatment duration and colostomy time. The approach offers substantial benefits in resource-limited settings by decreasing healthcare costs, hospital visits, and social stigma while maintaining comparable complication rates.
- Primary repair for low anorectal malformations reduces treatment duration from 730 days to 180 days compared to traditional three-stage approach.
- One- or two-stage repair showed no increase in postoperative complications versus three-stage repair in resource-limited settings.
- Primary repair eliminates prolonged colostomy time, reducing family healthcare costs and social stigma in low-income countries.
- Non-inferiority analysis confirms primary repair is as safe and effective as traditional staged approach for low ARMs.
- Surgical approach selection should be guided by surgeon experience and clinical judgment rather than defaulting to staged procedures.
Written by the GCMD Library team from the article.
Abstract
Background
Anorectal malformations (ARMs) have an incidence of up to 1 in 4000 live births and can require immediate neonatal surgery due to associated intestinal blockage. Due to limited surgical access, Ugandan children present late and 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 colostomies. By offering primary repair for ARMs in a resource-limited setting, we expect to: reduce healthcare expenditure by families, length of treatment, length of hospital stay, frequency of hospital visits, and social rejection.
Materials and methods
A pragmatic clinical trial was performed examining the effectiveness of primary repair (prospective arm) and comparing it with the three-stage repairs (retrospective arm).
Results
Of the 241 patients included for analysis—157 patients had a three-stage repair, whereas 84 patients had one- or two-stage repair. The median [IQR age at the last surgery (days) was 730.0 (365.0, 1460.0) vs 180.0 (90.0, 285.0)] in three-stage and one- or two-stage repairs, respectively. There was no difference in postoperative complications compared to patients who had three-stage repair. Patients who had a two-stage repair had less time with colostomy than those with three-stage repair. Non-inferiority analysis demonstrated that the primary repair approach was non-inferior to the three-stage approach.
Conclusions
Primary repair for ARM is effective in low-income settings. It allows for less time with colostomy with no difference in post-operative complications. The decision on approach for treatment depends on the surgeon’s experience and clinical judgment.