Perioperative Histologically Controlled Fistula Resection in Patients with Imperforate Anus and Perineal Fistula

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Introduction Postoperative constipation (PC) in patients with imperforate anus and perineal fistula (PF) has been reported in up to 60%. Histological studies of PF revealed innervation anomalies which seem to be one of the reasons for PC. Perioperative histologically controlled fistula resection (PHCFR) allows appropriate resection of PF and pull-down normoganglionic rectum at the time of posterior sagittal anorectoplasty (PSARP). Materials and Methods A total of 665 patients with anorectal malformations underwent surgery between 1991 and 2021. Of these, 364 presented PF; 92 out of them (41 F) were studied. Patients with sacral and spinal cord anomalies, neurological disorders, and cut-back anoplasty were excluded. PSARP was done on all patients. Hematoxylin-eosin staining and NADH Tetrazolium-reductase histochemical method were used. Four and more ganglion cells in the myenteric plexus represented a sufficient length of the resection. The continence was scored according to the modified Krickenbeck scoring system. Final scores ranged from 1 to 7 points. Values are given as median. Results A total of 65 (70.7%) patients presented an aganglionic segment in PF, and 27 patients presented hypoganglionosis. The median length of the resected fistula was 25 mm (interquartile range [IQR]: 20–30). The median total continence score was 7 (IQR: 6–7). Post-op constipation was observed in 6/92 (6.5%) patients. Conclusion PHCFR diminished PC to 6.5% of patients.

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Article · Nov 2023 · 1 min read

In brief

This study demonstrates that intraoperative histological assessment during fistula resection in imperforate anus patients reduces postoperative constipation from 60% to 6.5%. The technique identifies aganglionic or hypoganglionic segments in 70% of cases, enabling precise resection and pull-through of normally innervated bowel during posterior sagittal anorectoplasty.

70.7% of perineal fistulas in imperforate anus patients showed aganglionic segments, explaining high postoperative constipation rates.
Perioperative histological control ensures resection of abnormally innervated fistula tissue and pull-through of normoganglionic rectum.
PHCFR reduced postoperative constipation from reported 60% to only 6.5% in this 92-patient cohort.
Intraoperative frozen section with ≥4 ganglion cells in myenteric plexus confirms adequate resection margin.
Median continence score of 7/7 demonstrates excellent functional outcomes when normoganglionic bowel is preserved.

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