|Year : 2018 | Volume
| Issue : 4 | Page : 392-397
Evaluation of anal shift procedure in management of anterior displaced anus in female children
Department of surgery, Pediatric Surgery Unit, Al-Azhar University Hospital, New Damietta, Egypt
|Date of Submission||20-Oct-2018|
|Date of Acceptance||20-Mar-2019|
|Date of Web Publication||23-Apr-2019|
Pediatric Surgery Unit, Al-Azhar University Hospital, New Damietta 34517
Source of Support: None, Conflict of Interest: None
Background Anterior displaced anus (ADA) is a common anomaly in female children. There are several operative techniques for its treatment.
Aim The aim of this study was to present experience with anal shift procedure for the treatment of ADA in female children.
Patients and methods This is a prospective study that was conducted at the Pediatric Surgical Unit, Al-Azhar University Hospital, Damietta, during the period from October 2015 to September 2017. Fifteen female children with ADA underwent surgical correction by anal shift procedure. The anus position index was measured before and after the operation. Medical records of all patients were reviewed regarding operative time, intraoperative or postoperative complications, and conversion to other procedure. Parents’ satisfaction about cosmetic results of the technique was evaluated using a subjective score ranging from 0 to 4, where 0=no satisfaction, 1=fair satisfaction, 2=good satisfaction, 3=very good satisfaction, and 4=excellent satisfaction. All cases were followed up for a mean follow-up period of 12±2 months (range: 8–18 months).
Results A total of 15 female children with ADA were corrected with anal shift procedure. Their mean age was 3.06±1.03 years (range: 1–5 year). Anal functions were normal with acceptable anal position indices at the end of follow-up period for all patients. Complications were mild and treated conservatively. Only one case had superficial disruption of anterior incision, and secondary sutures were done with good result.
Conclusion Anal shift procedure appears to be a safe, simple, and effective surgical procedure for correction of ADA in female children.
Keywords: anal shift, anoplasty, anterior displaced anus, anterior displaced anus anterior displaced anus anterior displaced anus
|How to cite this article:|
Shahin M. Evaluation of anal shift procedure in management of anterior displaced anus in female children. Al-Azhar Assiut Med J 2018;16:392-7
|How to cite this URL:|
Shahin M. Evaluation of anal shift procedure in management of anterior displaced anus in female children. Al-Azhar Assiut Med J [serial online] 2018 [cited 2019 Aug 20];16:392-7. Available from: http://www.azmj.eg.net/text.asp?2018/16/4/392/256742
| Introduction|| |
Anorectal malformations (ARMs) are rare congenital anomalies, with absence or malposition of the anus. It affects 2–6 per 10 000 births worldwide. Asians were affected more than Europeans, and ARMs are somewhat more prevalent in boys (60%) than girls .
The etiology of ARMs is not accurately known, but it is supposed to be multifactorial. Genetic and environmental factors (e.g. adriamycin and etratinate) were thought to be responsible for ARMs . Some researchers have proposed an association with in-vitro fertilization  and diabetic mother ,. No single gene was found to be associated with ARMS. However, the persistent link between other congenital anomalies and genetic syndromes powerfully supports a genetic etiology ,.
Anterior displaced anus (ADA) is usually diagnosed on the basis of inspection by subjective assessment of the perineal position of the anus. However, the clinical measurement of anal position index (API, also called anogenital index or anal index) seems to be a valid objective method of identifying cases of ADA . API is calculated as the ratio of anus center–fourchette extent divided by coccyx–fourchette extent in girls and as the ratio of scroto-anal extent to scroto-coccygeal extent in boys. Normally, the mean API (±1 SD) has been reported to be 0.53–0.58 (±0.05–0.06) in boys and 0.44–0.46 (±0.05–0.08) in girls. ADA is diagnosed when the API value is less than 0.46 in males and less than 0.34 in females .
Most patients born with an ARM are anticipated to have some degree of functional defecation disorders .
There are different procedures for the treatment of displaced anus such as cutback, posterior anal transposition, posterior sagittal anorectoplasty, posterior anoplasty with sphincterotomy and anterior sagittal anorectoplasty. Some of these procedures are spacious, with less favorable cosmetic results and may require an initial diverting colostomy ,. Anal shift procedure was applied by Shah et al.  and had shown good functional and cosmetic results. This procedure is a simple and safe surgical procedure without colostomy. Herein, in this study, we presented our experience with anal shift procedure for the treatment of ADA.
| Patients and methods|| |
This is a prospective study that was conducted at Pediatric Surgical Unit, Al-Azhar University, Damietta during the period from October 2015 to September 2017. Fifteen female children with ADA underwent surgical correction by anal shift. Mean age of patients was 3.06±1.03 years (1–5 years). The diagnosis of ADA was done by calculation of API (the ratio of anus-fourchette extent to the extent between coccyx and fourchette in girls) ([Figure 1]).
|Figure 1 The anal position index is calculated as the ratio of anus–fourchette extent to the extent between coccyx and fourchette in girls (marked by three black points).|
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In lithotomy position, a transparent adhesive strip was applied from the inferior edge of the vulva to the tip of coccyx. Marks were done with a permanent marker at the tip of the coccyx, center of the anus, and inferior edge of the vulva. Then, the distances were measured by a flexible measuring tape marked in millimeters .
MRI for pelvic floor and perianal muscles was done for all cases to confirm its normal arrangement.
All patients started liquid diet 3 days before operative procedure. Rectal preparation by two fleet enemas was done (1 h before leaving home and then 15 min before leaving home).
Chemoprophylaxis in the form of third-generation cephalosporin 50–100 mg/kg was done for all cases
The infant was operated on while in the lithotomy position with endotracheal intubation. The operative field (perineum, both buttocks, and thigh) was painted by antiseptic solution (betadine) and draped by sterile towels. Two lateral plicating sutures were taken to stretch and elevate the skin bridge that is located between the displaced anus and vagina. Then, we mark a point B at 6 o’clock position on the skin, just behind the displaced anus, and mark point B- at 6 o’clock at the suggested site for new anus position. A line joining B:B- becomes midline incision. Another transverse incision midway between displaced anus and vagina was made between two points A- and A. It is as long as the B:B- line ([Figure 2])
First, the vertical incision, B:B-, was made, so that enough space was designed posteriorly in perineum, and then anterior dissection became easier. The incision was deepened slightly at point B on the posterior edge of the displaced opening. Then, the posterior wall of the new anus is dissected to sufficient depth. The anterior margin of muscle complex was detected. If anal stenosis was present, a vertical midline cut at 6 o’clock was placed on ano-rectum to permit the creation of sufficient size of anus.
Once, incision A:A- was made and deepened until the fibromuscular mass was splitted, the dissection between rectum and vagina was made mainly by blunt dissection. The depth of incision A:A- was at least half the length of A:A- to give good anovulvar distance, and care was exerted to safeguard the rectum ([Figure 3]a).
|Figure 3 (a) Incision A:A- now is made and deepened until the fibromuscular mass was splitted. (b) Lateral fibromuscular mass was closed in the midline to gain a sufficiently sizable perineal body.|
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Closure was done as follows: incision B:B- was closed at first. Suture was taken from point B to B- or the apex of the cut end of the anal verge. Two to three lateral sutures were taken as required. This closure pulls the anus backward. The lateral fibro-muscular mass of A:A- incision was closed in the midline by 4–0 Vicryl sutures ([Figure 3]b). Actually, three sutures were needed to gain a sufficient sizable perineal body. A second layer of sutures was used as required.
Then, the skin was closed longitudinally in midline, which pushed the anus backward. Sufficient anovulvar distance was achieved, and the anal shift is now completed ([Figure 4]).
All cases were followed up for a mean follow-up period of 12±2 months (range: 8–18 months). API was measured directly postoperatively and at the end of the study. Parents’ satisfaction about cosmetic results of the technique was evaluated using a subjective score ranging from 0 to 4, where 0=no satisfaction, 1=fair satisfaction, 2=good satisfaction, 3=very good satisfaction, and 4=excellent satisfaction.
Any complications (e.g. anal stenosis, retraction, infection, wound dehiscence, and soilin) were recorded. Laxative was given in the first week after surgery and then withdrawn, and any need for laxative after this period was documented.
The collected data were analyzed by statistical package for the social sciences (SPSS) software (IBM SPSS Inc., Chicago, Illinois, USA), running on IBM-compatible personal computer. Numerical data were expressed as mean and SD, whereas qualitative data were presented as number and percent distribution. For comparison between two means, the Student samples t-test was used, whereas paired samples t-test was used to compare the same variable at two different points of time. P value less than 0.05 was considered significant.
| Results|| |
In this study, 15 female children with ADA were corrected with anal shift procedure. Their mean age was 3.06±1.03 years (range: 1–5 years).
Seven (46.7%) patients with ADA were presented by chronic constipation, whereas eight (53.3%) patients were discovered accidentally during clinical examination.
The mean API before treatment was 0.27±0.027, which increased directly after surgery to 0.46±0.022, and at 1 year, API was 0.47±0.022. There was statistically significant increase of API directly after surgery and at 1 year when compared WITH preoperative values. However, there was no significant difference between values directly after surgery and those at 1 year.
Complications were in the form of postoperative need for laxative in two (13.3%) patients and wound infection and wound dehiscence in one (6.7%) patient. All complications were treated conservatively, except wound dehiscence, which needed further surgical intervention. The overall complications rate was 20.0% (three patients) ([Table 1]).
Before treatment, chronic constipation was significantly associated with reduced API when compared with cases without constipation (0.24±0.01 vs. 0.29±0.01, respectively), whereas after surgery, there was no association between API and chronic constipation as the main clinical presentation ([Table 2]).
| Discussion|| |
ADA is one of low ARMs and may be associated with chronic constipation or other malformations. It usually necessitates some form of surgical correction . This work presents our experience with correction of ADA by anal shift procedure, a relatively recent and not widely used procedure. We included only female children as it was previously reported that ADA had been reported to be more common among girls than boys . In addition, it was reported that ADA is more common in women. Later birth order and higher maternal age are risk factors for ADA .
Constipation represented the clinical presentation in approximately half of the studied female children. This coincides with previous works, which reported that the most common symptoms of ADA are constipation and dyschezia, which are usually present from infancy or from the time of weaning from breast feeding .
After correction, the mean API directly after surgery was 0.46±0.022, and at 1 year, API was 0.47±0.022. These values are comparable to mean normal values reported in previous works, as that of Chan et al.  who reported that the mean API in newborn females was 0.40±0.04. The API was initially introduced by Reisner et al.  as a reliable method of determining the position of normal anus. They found that that the mean API was 0.40±0.06 for girls. Thus, anal shift appears to be a promising procedure in its effectiveness for correction of ADA.
In this work, ADA was associated with chronic constipation. These results are comparable to previous studies which stated that ADA is a congenital anomaly of the anorectal area, and may be an important cause of constipation in infantile age and early childhood .
In addition, Rerksuppaphol and Rerksuppaphol  reported that ADA was the main cause of constipation in approximately one-third of all chronically constipated children. On the contrary, Bar-Maor and Eitan  found no significant difference in mean API between healthy children and those with idiopathic constipation. Herek and Polat  also claimed that ADA was not associated with an increased incidence of constipation, though girls with ADA were found to have more constipation than boys with ADA in their study.
The possible explanation for this contradiction may be attributed to different study designs and different ages of included children. In addition, the previous studies included both males and females, whereas in this study, we included only female patients in the age 1–5 years.
Ahmed  reported that four of 17 cases continued to have constipation, which were treated by simple laxatives. Cosmetically, the anal opening looked normal without stenosis with sufficient vulvo-anal distance. A single patient had superficial infection of the anterior incision with dehiscence, which underwent repair with good results.
There are a lot of surgical procedures to treat ADA. These comprise cutback, posterior anal transposition, posterior sagittal anorectoplasty, and anterior sagittal anorectoplasty. Some of these procedures are spacious, with less favorable cosmetic results and may require an initial diverting colostomy ,,. However, overall in this work, the results of the surgical procedure were acceptable, with complications responding to conservative treatment. Thus, anal shift procedure is a simple and safe surgical procedure with perfect functional and cosmetic results .
| Conclusion|| |
Anal shift procedure appears to be a simple, effective, and safe procedure for the treatment of ADA in female children. It does not require initial colostomy, and the minimal dissection reduces the chances of stricture and anal stenosis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
De Blaauw I, Wijers CH, Schmiedeke E, Holland-Cunz S, Gamba P, Marcelis CL et al.
First results of a European multi-center registry of patients with anorectal malformations. J Pediatr Surg 2013; 48:2530–2535.
Kluth D. Embryology of anorectal malformations. Semin Pediatr Surg 2010; 19:201–208.
Midrio P, Nogare CD, Di Gianantonio E, Clementi M. Are congenital anorectal malformations more frequent in newborns conceived with assisted reproductive techniques? Reprod Toxicol 2006; 22:576–577.
Frias JL, Frias JP, Frias PA, Martinez-Frias ML. Infrequently studied congenital anomalies as clues to the diagnosis of maternal diabetes mellitus. Am J Med Genet A 2007; 143A:2904–2909.
Castori M, Rinaldi R, Capocaccia P, Roggini M, Grammatico P. VACTERL association and maternal diabetes: a possible causal relationship? Birth Defects Res A Clin Mol Teratol 2008; 82:169–172.
Mundt E, Bates MD. Genetics of Hirschsprung disease and anorectal malformations. Semin Pediatr Surg 2010; 19:107–117.
Cuschieri A, Group EW. Anorectal anomalies associated with or as part of other anomalies. Am J Med Genet 2002; 110:122–130.
Genç A, Taneli C, Tansunğ N, Kasigra E, Yilmaz D, Küçükoğlu T, Onağ A. Evaluation of the location of the anus by modified technique in the neonate. J Pediatr Surg 2002; 37:80–82.
Harek O, Aziz P. Incidence of anterior displacement of the anus and its relationship to constipation in children. Surg Today 2004; 34:190–192.
Levitt MA, Pena A. Outcomes from the correction of anorectal malformation. Curr Opin Pediatr 2005; 17:394–401.
Becmeur F, Hofmann-Zango I, Jouin H, Moog R, Kauffmann I, Sauvage P. Three-flap anoplasty for imperforate anus: results for primary procedure or for redoes. Eur J Pediatr Surg 2001; 11:311–314.
Nunez-Ramos R, Fabbro MA, Gonzalez-Velasco M, Nunez Nunez R, Romanato B, Vecchiato L et al.
Determination of the anal position in newborns and in children with chronic constipation: comparative study in two European healthcare centres. Pediatr Surg Int 2011; 27:1111–1115.
Ibrahim AI, Korany M, Ammar SA. One stage posterior anal transposition for low and intermediate anorectal anomalies in females. Ann Pediatr Surg 2007; 3:92–96.
Herek O, Polat A. Incidence of anterior displacement of the anus and its relationship to constipation in children. Surg Today 2004; 34:190–192.
Rerksuppaphol S, Rerksuppaphol L. Anterior displaced anus: a common association with constipation in infancy. Asian Biomed 2010; 4:595–601.
Ottolenghi A, Sulpasso M, Bianchi S, Bettili G, Salloum A, Liber H. Displaced anus in childhood. Eur J Pediatr Surg 1994; 4:145–150.
Chan WT, Lee HC, Wang WN, Yeung CY, Jiang CB. Determination of the normal position of the anus in Taiwanese infants. Pediatr Neonatol 2009; 50:158–161.
Reisner SH, Sivan Y, Nitzan M, Merlob P. Determination of anterior displacement of the anus in newborn infants and children. Pediatrics 1984; 73:216–217.
Bar-Maor JA, Eitan A. Determination of the normal position of the anus (with reference to idiopathic constipation). J Pediatr Gastroenterol Nutr 1987; 6:559–561.
Ahmed H. Anterior displaced anus: a simplified approach. JPSS 2015; 9:1–52.
Abeyaratne M. Posterior transposition of anterior displaced anus. J Pediatr Surg 1991; 26:725–727.
Shah AJ, Bhattacharjee N, Patel DN, Ganatra JR. Anal shift: preliminary results. J Pediatr Surg 2003; 38:196–198.
Herek O. Anterior displaced anus: an accurate definitive term for choice of treatment? Pediatr Surg Int 2001; 17:501.
Tuggle DW, Perkins TA, Tunell WP, Smith EI. Operative treatment of anterior displaced anus: the efficacy and influence of age on results. J Pediatr Surg 1990; 25:996–997.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]