Division of Pediatric Surgery, Colorectal Center for Children, Cincinnati Children's Hospital Medical Center, Cincinnati,OH 45229, USA.
J Pediatr Surg. 2011 Jun;46(6):1250-5. doi: 10.1016/j.jpedsurg.2011.03.064.
Cloacal malformations represent the most complex of genitourinary/anorectal anomalies. We have encountered a unique group of complications in referred patients after failed attempted repairs elsewhere and chose to review this experience with the hope of identifying pitfalls to avoid during the primary repair.
In our series of 509 cloacas, 95 were repaired elsewhere but required reoperation. These cases were reviewed for specific indications for reoperation and methods used for reoperative repair. Key findings at reoperation to explain the complication(s) were specifically sought.
Indications for reoperation included the following: persistent urogenital sinus (46), rectal stricture or acquired atresia (45), acquired vaginal atresia or stricture (45), mislocated rectum (36), urethrovaginal fistula (16), rectal prolapse (12), urethral atresia or stricture (7), and rectovaginal fistula (5). Most patients had more than one indication. In cases of persistent urogenital sinus, the surgeons were unaware of the presence of a cloaca, referring instead to the malformation as a "rectovaginal fistula." From our reading of the operative reports of the original operations, we ascertain that rectal stricture, atresia, or fistula that occurred was most likely related to tension or ischemia. Prolapse was associated with poor pelvic musculature. The average length of the common channel of those patients with vaginal and urethral problems was 4.1 cm.
We have observed key complications requiring reoperation in a large series of cloacal malformations that are potentially avoidable. A persistent urogenital sinus can be avoided by properly diagnosing a cloaca and repairing the entire malformation and not just the rectum during the initial repair. Vaginal and urethral complications occurred mainly in patients with a common channel longer than 3 cm. Repair of cloacas with common channels longer than 3 cm requires familiarity with a complex decision-making process, and atresias, strictures, and fistulae can be avoided with adequate mobilization of structures and preservation of blood supply. Rectal prolapse occurrence relates to the quality of the perineal muscles. Reoperations can restore the anatomy, but the functional results are not as good as those achieved after primary repair.
腔肛畸形代表了最复杂的泌尿生殖/肛肠畸形。我们遇到了一组在其他地方修复失败的转诊患者的独特并发症，并选择回顾这些经验，希望能确定在初次修复过程中避免的陷阱。
在我们的 509 例腔肛畸形患者中，有 95 例在其他地方修复，但需要再次手术。对这些病例进行了回顾，以确定再次手术的具体指征和再手术修复的方法。特别寻找再次手术时发现的并发症的关键发现。
再次手术的指征包括以下内容：持续性泌尿生殖窦（46 例）、直肠狭窄或获得性闭锁（45 例）、获得性阴道闭锁或狭窄（45 例）、直肠位置不当（36 例）、尿道阴道瘘（16 例）、直肠脱垂（12 例）、尿道狭窄或闭锁（7 例）和直肠阴道瘘（5 例）。大多数患者有不止一个指征。在持续性泌尿生殖窦的病例中，外科医生不知道腔肛的存在，而是将畸形称为“直肠阴道瘘”。从我们对原始手术的手术报告的阅读中，我们确定发生的直肠狭窄、闭锁或瘘管很可能与张力或缺血有关。脱垂与骨盆肌肉无力有关。有阴道和尿道问题的患者的共同通道的平均长度为 4.1 厘米。
我们在一组大型腔肛畸形患者中观察到了需要再次手术的关键并发症，这些并发症是可以避免的。通过正确诊断腔肛并在初次修复时修复整个畸形而不仅仅是直肠，可以避免持续性泌尿生殖窦的发生。阴道和尿道并发症主要发生在共同通道长度超过 3 厘米的患者中。对于共同通道长度超过 3 厘米的腔肛修复，需要熟悉复杂的决策过程，通过充分的结构移动和保持血液供应，可以避免狭窄、闭锁和瘘管的发生。直肠脱垂的发生与会阴肌肉的质量有关。再次手术可以恢复解剖结构，但功能结果不如初次修复。
