Appendix/ColorectalAssessment of the Heineke–Mikulicz anoplasty for skin level postoperative anal strictures and congenital anal stenosis☆,☆☆
Section snippets
Methods
We retrospectively reviewed all patients who underwent HMA at our Center for skin level strictures following PSARP or for congenital anal stenosis from 2014 to 2017. It should be noted that it is our current practice to perform routine dilations after our own primary PSARP but not after redo PSARP given that this population of patients is generally older than patients at the time of primary PSARP, and they often have a history of previous traumatic dilation. For patients in whom dilations are
Results
28 patients (19 males, 9 females) underwent HMA over the study period. The mean age at the time of HMA was 5.8 years (range 0.5–24.4). Patients underwent HMA at a mean of 1.9 (range 0.2–13.1) years following PSARP. 25/28 (89%) of patients were symptomatic from their stricture, with all 25 patients presenting with constipation and 9/28 (32%) having one or more episodes of fecal impaction. The remaining 3 patients were diagnosed with a stricture on routine examination after PSARP. 26 had
Discussion
The optimal surgical management of a postoperative stricture after PSARP is not well defined, although a number of techniques exist [10], [13], [14], [15]. We previously reported on the technique of a Heineke–Mikulicz-like anoplasty for the treatment of skin-level strictures [10]. Since the effectiveness and durability of this procedure remain unknown we chose to evaluate the technique further, focusing on its safety and longer term functional outcomes. Our results show that this procedure can
Conclusion
The Heineke–Mikulicz anoplasty is a simple procedure that can be performed in the outpatient setting to treat skin-level anal strictures after primary and redo PSARP and in select cases of congenital anal stenosis. Our results suggest that this procedure has good durability with a low recurrence rate.
References (21)
- et al.
Reoperations in anorectal malformations
J Pediatr Surg
(2007) - et al.
Posterior sagittal anorectoplasty: important technical considerations and new applications
J Pediatr Surg
(1982) - et al.
Is daily dilatation by parents necessary after surgery for Hirschsprung disease and anorectal malformations?
J Pediatr Surg
(2012) - et al.
Ventral longitudinal stricturotomy and transversal closure: the Heineke–Mikulicz principle in urethroplasty
Urology
(2010) - et al.
Surgical techniques for repair of peripheral pulmonary artery stenosis
Semin Thorac Cardiovasc Surg
(2017) - et al.
Use of a Heineke–Mikulicz like stricturoplasty for intractable skin level anal strictures following anoplasty in children with anorectal malformations
J Pediatr Surg
(2016) - et al.
Diamond flap anoplasty in infants and children with an intractable anal stricture
J Pediatr Surg
(1994) - et al.
Anoplasty for the treatment of anal stenosis
Am J Surg
(1998) Anal stenosis
Surg Clin North Am
(1994)- et al.
Rectal atresia and stenosis: unique anorectal malformations
J Pediatr Surg
(2012)
Cited by (17)
Expertise Area 1.7: Ano-uro-rectal malformations
2024, Rare and Complex UrologyNurses' Experiences With Anal Dilatations in Babies With Anorectal Malformations – A Focus Group Interview Study
2023, Journal of Pediatric SurgeryPerineal cutaneous appendix and anorectal malformation
2023, Anales de PediatriaThe cutback revisited — The posterior rectal advancement anoplasty for certain anorectal malformations with rectoperineal fistula
2022, Journal of Pediatric SurgeryCitation Excerpt :Those patients whose perineal fistula opened outside of (and anterior) to the sphincter muscle complex were not considered appropriate candidates for this procedure and underwent PSARP, with fistula and distal rectum mobilization and re-location to the center of the sphincters. Patients whose anal openings were centered within the sphincter complex but had a skin-level stricture were managed with either dilations or a Heineke-Mikulicz anoplasty [6]. All patients were screened for other components of the VACTERL association (renal ultrasound, spine x-ray, and echocardiography) and spinal cord abnormalities (spinal cord ultrasound or MRI) prior to surgical repair.
Are routine postoperative dilations necessary after primary posterior sagittal anorectoplasty? A randomized controlled trial
2021, Journal of Pediatric SurgeryCitation Excerpt :HMA offers an excellent solution for strictures involving only the mucocutaneous anastomosis. A study by Halleran et al demonstrated that HMA for strictures, a technique originally described in 2016 [20], is safe with immediate and sustained long term results [21]. During their study period, 28 patients underwent HMA, with an average increase of the neo-anus size from pre-procedural to post-procedural Hegar 8 to Hegar 16 respectively.
Treating pediatric colorectal patients in low and middle income settings: Creative adaptation to the resources available
2020, Seminars in Pediatric SurgeryCitation Excerpt :Cicatrization of the muco-cutaneous anastomosis after an anoplasty procedure, or at the anorectal anastomosis in a Hirschsprung pull-through procedure, can lead to devastating outcomes. As previously mentioned, where post-operative follow-up care is expected to be extremely limited, surgeons may elect to create an anoplasty that is wider than the limits of the anal sphincter complex or a Heineke-Mikulicz anal stricturoplasty.1,46,63 Routine serial home dilation of the anastomosis is usually started within 2–4 weeks after the procedure.
- ☆
Author Contribution:
Study conception and design: DRH, AVS, RMR, LW, CR, ACG, MAL, RJW
Acquisition of data: DRH, AVS, RMR, HA, LW
Analysis and interpretation of data: DRH, AVS, RMR, HA, LW, CR, ACG, MAL, RJW
Drafting of manuscript: DRH, AVS, RMR, HA, CR, ACG, MAL, RJW
Critical revision of manuscript: DRH, AVS, RMR, HA, LW, CR, ACG, MAL, RJW
- ☆☆
How this paper will improve care: The Heineke–Mikulicz anoplasty is a safe and effective outpatient procedure for the treatment of skin-level strictures after PSARP and select cases of congenital anal stenosis and may provide an alternative treatment to routine dilations after primary PSARP.