Anal atresia, breech closed
What is anal atresia, breech closed:
Anal atresia is the condition when the anus is completely closed or the opening for normal pooping is not formed.
How to recognize it:
Children with completely closed breeches are unable to poop after birth, their tummy is swollen, and it is usually immediately noticed. Sometimes, there may be a duct (fistula) coming from the skin in the anterior part of the anus or close to the vaginal entrance in girls, and these patients may be noticed later if they are not carefully examined.
How it occurs, what are the causes:
In the first weeks of pregnancy, the end of the intestine and the urinary canal open into a common space (cloaca), and in girls the vagina also opens here. In the 7th week of pregnancy, this space is divided to form the urinary canal and anus in boys, and the urinary canal, vagina and anus in girls, and opens out of the body. However, in children, 1/5000 of the normal anus opening does not occur and it opens to the skin, urinary tract or vaginal entrance in girls or a common channel with a thin channel. The exact cause of the disease is not clear, only some patients have genetic factors.
What types are there:
There are various classifications of anal atresia in boys and girls. However, in practice, it can be divided into three as low, high and medium according to the distance of the most end part of the intestine to the skin, which should be the anus. If the end of the intestine is close to the skin or opens here with a thin channel (fistula), it is called low-type anal atresia, and if it is too far from the skin, it is called high-type atresia. Those at intermediate distances are called intermediate tipatresia. Almost all moderate and high atresia have a connection (fistula) with the urinary tract, and the higher it is, the higher the incidence of additional disease (heart, digestive system, urinary tract, skeletal system diseases). In girls, the middle atresia joins the vaginal entrance, while the high ones, the urinary tract, vagina and the last part of the intestine, merge with a common channel, this channel is opened on the skin as a single hole where the vagina should be.
What to do after it is detected:
After the first attempts are made in the child whose breech is found to be closed after birth, it is decided that the atresia is low or high type, then additional diseases are investigated. In low-type atresia, the breech area is close to normal, well developed, and poop may be coming from a duct (fitula) opening to the skin. In high-type atresia, the breech area is flat, not well developed, and may be connected with the urinary canal and fistula, and in girls, poop and urine may come from a single opening in the genital area. Apart from examination, radiological and endoscopic imaging methods are also used for this distinction. In low atresia, anal opening surgery is performed in a single session immediately after birth, followed by early or late dilatation. In high type, colostomy is opened immediately and breech surgery is performed 3-6 months later.
How the operation is performed:
The aim in anal atresia surgery is to bring the last part of the intestine to the place where the anus should be, in the middle of the muscles that allow pooping. The most important points of the surgery are to free the intestines and suture them comfortably, with the narrow end below, in the middle of the funnel-shaped muscles, with a sufficiently wide breech opening. There are differences in the operation of low and high type atresia:
Low type atresia: In low type atresia, the intestine has no connection with the urinary tract and the last part of the intestine is close to the skin, without the need for a colostomy, the intestine can be brought to the anus point in one step. The place where the anus should be is determined and marked with the help of muscle stimulator, the last part of the intestine is released sufficiently and sutured all around with absorbable sutures. Two weeks after the operation, the anus is included in the dilatation program, starting from the thinnest bougie and widening up to the number 12-13, dilatation is performed.
High type atresia: The surgical approach is almost the same in high and medium type atresia. First, the colostomy is opened, so that the child is fed and grown normally, and the main post-operative area is kept clean and healed. The main operation, retraction of the intestine to the breech region, is performed after 3-6 months, according to the surgeon’s preference. The last part of the intestine is mostly connected with the urinary canal and rarely with the bladder outlet by a thin fistula, this connection is separated and sutured. In girls, the intestine is separated from the common channel where the urinary canal, vagina and the end of the intestine are opened, freed and sutured all around where the anus should be, the vagina and urinary canal are pulled forward and sutured to the skin. These procedures can be done with an approach from the breech region while the child is lying face down, by using a muscle stimulant, it is placed in the middle of the muscle bundle that provides poop holding. However, in very high type atresia, if the intestine cannot be brought to the breech region, it may be necessary to liberate the intestine sufficiently with an incision made from the abdomen. Two weeks after the operation, when the wound healing is complete, the patient is taken to the dilatation program again. The colostomy is usually closed after 3 months.
How is the post-operative period:
In low-type atresia after surgery, the breech area is cared for and dressed. Since the child will poop immediately, the area should be washed after each poop and antibiotic cream should be used, it usually heals without any problems. In high-type atresia, it is easier to care and heal since there is no poop since there is a colostomy. Since the fistula is repaired in the urinary canal, the urinary catheter is kept for two weeks and then removed. A dilatation program is required after every anal atresia surgery because there is narrowing around the anus after wound healing. The colostomy can be closed after about 3 months, when the anus is wide enough.
What are the complications:
Infection around the anus may occur in the early postoperative period. Narrowing of the anus and intestines may be seen. If the intestine planted in the anus is tense, it may retract. If care is not taken while disconnecting the connection to the urinary canal, narrowing or pocket-like width can be seen in the urinary canal or fistula may recur. Constipation, poop incontinence, gas and liquid poop incontinence can be seen in the late period. Constipation is more common in low-type atresia, and stool incontinence and incontinence are more common in high-type atresia. If the breech stenosis is evident despite dilatation, and the breech could not be brought to the middle of the muscle bundle, the surgery may need to be performed again.
