Pediatric Surgical Care of Anorectal Malformations: A Global Survey

Pediatric Surgical Care of Anorectal Malformations: A Global Survey | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Pediatric Surgical Care of Anorectal Malformations: A Global Survey Vatche Melkonian, Sage A Vincent, Luis De La Torre, The Hendren Project Global Surgery Research Initiative, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8764567/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Purpose All patients born with anorectal malformations (ARMs) deserve high-quality healthcare, including appropriate neonatal screening, perioperative management, and long-term follow-up. This study examined global pediatric surgical practices for ARM management, identifying areas of consensus and variability in perioperative care and reported outcomes. Methods A multi-center survey distributed by The Hendren Project (a global networked community of pediatric surgeons) invited surgeons to retrospectively review their ten most recent primary ARM reconstructions, excluding reoperations. Data were compared by country/continent and World Bank income. Results A total of 144 surgeons from 90 hospitals in 50 countries reported outcomes for 900 patients. Sacral radiographs were inconsistently obtained, with 34.2% lacking lateral views and 21.9% missing anterior-posterior views. The complication rate after PSARP was 27.2%, including dehiscence (11.7%), wound infection (7.4%), and stricture (6.9%). Divided stomas were more common than loop colostomies (66.3% versus 28.8%). Postoperative anal dilations were performed by 92.6% of surgeons. Reported complication rates did not differ significantly by region or income category. Conclusion This global survey demonstrates wide regional and income-based variability in ARM perioperative care, spanning screening, operative strategy, timing, and postoperative management. Inconsistent sacral and spinal screening, especially in low-resource settings, highlights needs for standardized pathways and context-aware quality improvement efforts worldwide. Colorectal global surgery anorectal malformation ARM survey international Introduction The successful management of anorectal malformations (ARMs) extends far beyond the primary surgical repair. While some malformations have a favorable prognosis for bowel control, inadequate perioperative care can lead to long-term complications, including fecal incontinence. Optimizing perioperative management is crucial to achieving the best functional outcomes for these patients [ 1 ]. In addition, comprehensive screening for associated medical conditions is essential to avoid further complications and morbidity [ 2 ]. The importance of delivering quality healthcare to children with anorectal malformations is essential, as the outcomes may have lifelong implications. A well-established definition of quality healthcare is “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” [ 3 ]. A common goal shared across all pediatric surgeons is that all patients with these congenital anomalies should receive high-quality standards of care, regardless of where they are born. This includes comprehensive neonatal screening, appropriate surgical planning and technique, acceptable complication rates, and continued postoperative care [ 4 ]. Perioperative care for ARMs encompasses three key stages. The preoperative phase involves the timing of diagnosis, screening for associated anomalies, and determining the appropriate surgical approach, whether primary repair without colostomy, staged repair with colostomy, or delayed primary repair without colostomy. The intraoperative phase focuses on performing a technically precise operation to optimize anatomical correction and functional outcomes. The postoperative phase variably includes anal dilations to prevent stricture formation and bowel management strategies to address constipation and fecal incontinence [ 1 , 4 ]. Despite the availability of established perioperative guidelines, significant variations in practice exist worldwide [ 4 , 5 ]. Barriers to this goal may come from variations of clinical practice, both in the United States and internationally, secondary to differences in national culture, medical education, residency/fellowship training, health beliefs, and longstanding traditions [ 5 – 7 ]. Despite broad recognition that resource availability influences surgical care globally, there are limited data describing how these differences manifest in the perioperative management of anorectal malformations at the level of day-to-day surgical decision-making. Existing global surgery studies often focus on mortality or access to surgery, rather than specific diagnostic and perioperative processes that are potentially modifiable [ 8 ]. Leveraging The Hendren Project, a global collaborative network of pediatric surgeons, provides a unique opportunity to benchmark current practices across diverse healthcare systems using a standardized framework. By identifying areas of consistent practice alongside modifiable gaps, this study aims to generate actionable targets for education, quality improvement, and future collaborative initiatives rather than merely describing resource disparities. Our objective was to examine the management of anorectal malformations by pediatric surgeons worldwide, assessing areas of consensus and variability regarding perioperative care, while also reviewing reported outcomes. By highlighting differences in practice, this study aims to inform future educational outreach efforts and quality improvement initiatives in an attempt to decrease surgical care disparity for these patients, regardless of geographic location. We hypothesized that substantial variation would exist in patient care at both the institutional and continental levels. Methods Study Setting A survey was distributed electronically through The Hendren Project, a global networked community of pediatric surgeons and urologists, on March 15th, 2024. Surgeons could participate by retrospectively reviewing the past ten patients who underwent reconstruction for anorectal malformations at their institution. Only primary cases, no reoperations, could be included. Each author was responsible for obtaining the necessary local approvals from their ethical review boards. Given the relative rarity of ARMs, ten cases were felt to be a representative sample of cases. The Hendren Project was selected as the distribution platform because it is an established international network of pediatric surgeons with a mission aligned to collaborative benchmarking and dissemination of best practices. Its global reach enabled participation from a broad range of healthcare systems using a standardized survey instrument. Study Population Although the total number of Hendren Project members receiving the survey invitation was known, eligibility required completion of at least ten primary ARM repairs, and this denominator could not be verified. As such, a formal response rate could not be calculated. However, participating surgeons represented 90 hospitals across 50 countries and five continents, providing broad geographic representation. Participants were provided with a consent form explaining the purpose, benefits, and possible risks of enrolling in the survey. The survey post-card containing the link read as follows: “If your current center has completed at least ten primary operations to repair any anorectal malformation, you have obtained any necessary regulatory approvals, and you wish to participate in this study, please complete this survey”. Data Collection Participation included the opportunity for up to two contributing surgeons per institution to be listed as co-authors for their contribution to the data collection. Authorship was not intended as an incentive, but was intended to reflect the work required to obtain ethical permissions and review patient data. The survey was conducted securely in Qualtrics. In addition to this, the survey asked for the surgeon’s city, country, and hospital. At no time was any identifying information requested about the ten reported patient cases. The survey proceeded with a repeating cycle of up to 16 multiple-choice questions, some of which would auto-populate depending on the previous answer. This would cycle through ten times before the survey was considered completed to receive information on all ten unique patients. Many of the questions also had the option to submit a further explanation, for example, if the choice of “other” was selected. Survey questions can be found in the appendix. To minimize duplicate institutional submissions, survey responses were linked to the institution name, and duplicate entries from the same center were reconciled during data cleaning. A copy of survey questions can be seen in Supplemental Fig. 1. Data Analysis Data was analyzed at the patient level and at the hospital level. At the patient level, categorical variables are presented as frequency and percent. At the hospital level, the data was broken up into five continents: Africa, Asia (including Australia), Europe, North America, and South America. Continents and countries were subdivided into World Bank Income classes: low/low-middle, upper-middle, and high. This classification system has been previously used in the global health literature [ 8 , 9 ]. Hospital level variables were created by aggregating patient-level data within a hospital and presented as percentages. For each variable, within each hospital or each row, the number of records that indicated “yes” for a variable was summed and divided by the total number of patients with responses to that variable and converted to a percentage. These numeric variables were summarized using frequency, and median (interquartile range), as appropriate. Comparisons between continents and World Bank Income classes were made using Kruskal-Wallis test, adjusting for the non-normality of the distribution. The significance level was assumed to be α = 0.05. R version 4.4.2 was utilized for all statistical analyses. Ethical Considerations The coordinating institution obtained IRB approval (COMIRB No: 24–0202). Participating centers were instructed to obtain local IRB approval or a waiver in accordance with institutional and national regulations; documentation was not centrally verified. Results For this survey, 144 surgeons responded from 90 hospitals in 50 different countries, reporting 900 patients. A response rate is not able to be captured due to changing listservs and variations in email deliverability. The sub-type of anorectal malformation as well as the summary of newborn screenings and approach to repair can be seen in Table 1 . Sacral radiographs, widely available and recognized as a key prognostic tool for assessing future bowel control in patients with anorectal malformations, are still not routinely performed for all patients, with 34.2% lacking lateral views and 21.9% missing anterior-posterior (AP) views. The complication rate after PSARP was 27.2%, with the most common being dehiscence (11.7%), wound infection (7.4%), and stricture (6.9%). Post-operative anal dilations were performed by 92.6% of surgeons (Table 1 ). Table 1 Summary of patient anorectal malformation subtype, newborn screening and approach to repair reported in a global survey of pediatric surgeons. All Patients (n = 900) a Anorectal Malformation, n (%) Recto-perineal fistula 238 (26.5%) Recto-vestibular fistula 219 (24.4%) Recto-urethral bulbar fistula 109 (12.1%) Recto-urethral prostatic fistula 69 (7.7%) Recto-bladder neck fistula 42 (4.7%) Recto-vaginal fistula 30 (3.3%) No fistula 99 (11.0%) Cloaca 62 (6.9%) Other 31 (3.4%) Newborn screening, n (%) Sacral radiograph AP 684 (78.1%) Sacral radiograph lateral 576 (65.8%) Renal ultrasound 790 (90.2%) Spinal ultrasound/MRI 440 (50.2%) Pelvic ultrasound b 54/62 (87.1%) Echocardiogram 708 (80.8%) Surgical Repair Age at time of primary repair, n (%) 3 years of age 47 (5.2%) Colostomy created during newborn period, n (%) 563 (62.7%) Colostomy during primary repair, n (%) 599 (67.8%) Complications following primary repair, n (%) Dehiscence 104 (11.7%) Wound infection 66 (7.4%) Stricture 61 (6.9%) Prolapse 39 (4.4%) Need for reoperation 43 (4.8%) Mortality 5 (0.6%) None 648 (72.8%) Use of postoperative anal dilations, n (%) 826 (92.6%) (AP- anterior posterior; MRI- magnetic resonance imaging) a In some circumstances, survey respondents omitted answers to some questions, as such not all categories summate to reported totals b Pelvic ultrasound question only asked when the patient’s ARM pathology was cloaca. Colostomy creation was done at less than six months in age in 84.8% of patients, with a small minority undergoing delayed colostomy (Table 2 ). There were more responses to the colostomy creation and closure question (n = 621) than colostomy present during primary repair (n = 599), indicating that some patients underwent colostomy outside of the primary repair, as in the case of a complication. Surgeons reported more frequent use of divided stoma (66.3%) compared to loop (28.8%). Complications after colostomy creation occurred in 18% of patients, most frequently wound infection, followed by need for reoperation. Colostomy closure was performed between six months to two years of age in 70% of reported patients (Table 2 ). Complications occurred in 15% of patients following their colostomy closure, most commonly wound infection (12.1%). Table 2 Summary of timing, technique, and complication rate associated with colostomy creation and closure for pediatric patients with anorectal malformations, as reported by a global survey of pediatric surgeons. All Patients (n = 621) a Colostomy creation Age at colostomy creation, n (%) 3 years of age 12 (2.0%) Type of colostomy created, n (%) Divided/end 406 (66.3%) Loop 176 (28.8%) Hartmann pouch 11 (1.8%) Other 19 (3.1%) Complications following colostomy creation, n (%) Dehiscence 35 (5.2%) Wound infection 59 (9.6%) Stricture 19 (3.1%) Need for reoperation 41 (6.7%) Mortality 1 (0.2%) None 503 (81.9%) Colostomy closure Age at colostomy closure, n (%) 3 years of age 62 (10.5%) Complications following colostomy closure, n (%) Dehiscence 23 (3.9%) Wound infection 71 (12.1%) Stricture 6 (1.0%) Hernia 9 (1.5%) Need for reoperation 16 (2.7%) Mortality 1 (0.2%) None 496 (84.2%) a In some circumstances, survey respondents omitted answers to some questions, as such not all categories summate to reported totals There was a significant difference in the distribution of World Bank Income Levels when stratifying by continent (Table 3 , p < 0.001). The majority of hospitals reporting in Africa and Asia were classified as low/lower-middle income (77.3% and 52.4%, respectively). In North America, 50% of hospitals were classified as upper-middle income, while 92.3% of hospitals in South America were classified as the same. Europe, meanwhile, had a significant proportion of hospitals categorized as high income (85.7%). Table 3 Frequency of hospital classification by World Bank Income Level summarized by continent of practicing pediatric surgeons responding to a global survey about anorectal malformation management. Africa (n = 22) Asia (n = 21) Europe (n = 14) North America (n = 18) South America (n = 14) a p-value World Bank Income Level, n (%) < 0.001 Low/lower-middle 17 (77.3%) 11 (52.4%) 0 (0.0%) 2 (11.1%) 1/13 (7.7%) Upper-middle 5 (22.7%) 5 (23.8%) 2 (14.3%) 9 (50.0%) 12/13 (92.3%) High 0 (0.0%) 5 (23.8%) 12 (85.7%) 7 (38.9%) 0/13 (0.0%) a South America is represented by surgeon respondents from 14 countries, one of which is Venezuela. Venezuela’s World Bank Income Level is “Not Classified”, and as such, was removed from frequency calculations. The median percentage of patients who underwent sacral radiograph (AP and lateral), spinal ultrasound or spinal MRI, and echocardiogram as part of their screening work up for associated anomalies different significantly by World Bank Income Level (Table 4 ). Spinal ultrasound was performed more frequently in upper-middle and high groups (55% and 100% vs 0%, p < 0.001). Echocardiogram was also more frequently performed in the upper-middle and high groups than low/lower-middle (100% and 100% vs 70%, p = 0.002). There was no difference in the frequency of screening with renal ultrasound or pelvic ultrasound (in the case of cloaca patients). Table 4 Comparison of newborn anomaly screening modalities performed for patients with anorectal malformations by the World Bank Income Level classification of the hospital, as reported by responding pediatric surgeons to a global survey. Low/lower-middle a (n = 31) Upper-middle a (n = 34) High a (n = 24) p-value Imaging modality, median percentage (IQR) Sacral radiograph (AP) 90 (15, 100) 100 (100, 100) 95 (17.8, 100) 0.005 Sacral radiograph (lateral) 70 (20, 90) 100 (72.5, 100) 25 (0, 100) < 0.001 Renal ultrasound 100 (80, 100) 100 (100, 100) 100 (90, 100) 0.407 Spinal ultrasound/MRI 0 (0, 30) 55 (11.4, 100) 100 (73.9, 100) < 0.001 Pelvic ultrasound b 0 (0, 0) 0 (0, 10) 0 (0, 10) 0.995 Echocardiogram 70 (40, 100) 100 (90, 100) 100 (100, 100) 0.002 (IQR- interquartile range; AP- anterior posterior; MRI- magnetic resonance imaging) a Venezuela’s World Bank Income Level is “Not Classified”, and as such, any hospitals in Venezuela were removed from this analysis. b Pelvic ultrasound question only asked when the patient’s ARM pathology was cloaca. With regards to primary ARM repair, the median percentage of patients who underwent colostomy creation during newborn period and during primary repair was significantly different between the different Work Bank Income Levels (Table 5 ). The age at time of primary repair was also significantly different by World Bank Income Level for all age subgroups, except 6 months to 1 year of age. Table 5 Comparison of operative repair timing, approach, and complications for patients with anorectal malformations by the World Bank Income Level classification of the hospital, as reported by responding pediatric surgeons to a global survey. Low/lower-middle a (n = 31) Upper-middle a (n = 34) High a (n = 24) p-value Surgical repair, median percentage (IQR) Colostomy created during newborn period 70 (55, 80) 70 (60, 89.7) 50 (37.5, 60) < 0.001 Colostomy created during primary repair 70 (60, 100) 80 (60, 90) 50 (40, 60) < 0.001 Use of postoperative anal dilations 90 (90, 90) 90 (86.8, 90) 90 (80, 90) 0.245 Age at time of primary repair, median percentage (IQR) < 6 months of age 30 (10, 40) 30 (10, 48.6) 60 (47.5, 72.5) 3 years of age 0 (0, 5) 0 (0, 10.8) 0 (0, 0) 0.006 (IQR- interquartile range; AP- anterior posterior; MRI- magnetic resonance imaging) a Venezuela’s World Bank Income Level is “Not Classified”, and as such, any hospitals in Venezuela were removed from this analysis. Discussion This study provides a comprehensive analysis of global practices in the management of anorectal malformations (ARMs), highlighting areas of consensus and variability among pediatric surgeons. The findings underscore significant disparities in perioperative care, influenced by geographical location, healthcare infrastructure, and access to resources. These variations are particularly evident in the use of sacral radiographs, surgical techniques, and postoperative management strategies, all of which have implications for long-term functional outcomes in children with ARMs. We observed regional differences in the proportion of recto-perineal fistulas. This finding may reflect differences in referral patterns (e.g., complex malformations preferentially referred to specialty centers), regional variation in diagnostic classification practices, or survivorship and access effects in which more complex malformations may be underrepresented in settings with delayed presentation or limited access to neonatal surgical care. Because this study relied on retrospective sampling of recent institutional cases without external verification, we cannot determine whether these differences represent true epidemiologic variation versus ascertainment or classification differences. Surgical techniques for ARM repair also vary widely, particularly in the approach to colostomy creation. The majority of surgeons in this study reported performing divided colostomies (66.3%) while other surgeons reported the preference for loop colostomies (28.8%). Traditional teaching has supported divided colostomies over the loop colostomy to decrease the incidence of urinary tract infections, although recent studies have suggested a similar incidence of complications with the use of either method [ 9 ]. One study did however suggest an increased risk of prolapse with loop colostomies [ 10 ]. Of note, the goal of colostomy creation for patients with ARMs is to divert the fecal stream, avoid potential urinary tract infection, and allow for a future high-pressure distal colostogram to define the anatomy pre-operatively. However, in select cases where patients have an opening in their perineum, such as with a perineal fistula or rectovestibular fistula, an end colostomy and Hartmann’s pouch could be considered [ 11 ]. The risk to this approach is in the event of a dehiscence, retraction, or acquired atresia after a PSARP, this would result in a blind segment of bowel, with no point of egress. Another significant finding of this survey was delayed timing of definitive surgical repair. Overall, 30.6% of patients did not undergo repair until after one year of age, and 62.4% were repaired after six months of age. These findings are notable given the well-documented advantages of early anorectoplasty, which include the potential to avoid colostomy, reduce the total number of operations, and optimize long-term bowel function. Harumatsu et al. demonstrated superior long-term bowel outcomes among patients undergoing early repair ( 5 months) [ 12 ]. Additional studies support these findings, suggesting that earlier repair may maximize development of defecation reflexes and is associated with improved continence and quality of life—particularly when repair is performed before three months of age for non-complex malformations and within the first year of life for more complex anomalies [ 13 , 14 ]. Although delayed repair was common in this cohort, the survey was designed to capture institutional practice patterns rather than the clinical reasoning underlying individual cases. As such, follow-up queries were not performed to clarify surgeon-specific decision thresholds, including reasons for delaying repair beyond one year or selecting staged versus primary repair. Future iterations of this survey should incorporate targeted questions addressing factors that influence timing decisions, such as referral delays, neonatal intensive care unit capacity, anesthesia availability, access to contrast studies, surgeon availability, and family travel constraints. Importantly, variability in age at repair and completeness of newborn screening appeared closely linked to resource setting. Centers in lower-income regions more frequently reported delayed repair and incomplete screening, likely reflecting challenges related to early diagnosis, referral pathways, diagnostic imaging access, anesthesia availability, and competing health system priorities. These differences do not necessarily represent deviations from best practice but rather reflect structural constraints that shape what care delivery is feasible in different settings [ 15 ]. Within this context, the decision to create a colostomy prior to definitive repair warrants careful consideration. While colostomy remains an appropriate and often necessary component of ARM management, it commits patients to multiple operations—colostomy creation, posterior sagittal anorectoplasty, and colostomy closure—each requiring exposure to general anesthesia. Emerging data have raised concerns regarding early childhood anesthesia exposure and potential associations with neurodevelopmental delay in children under two years of age [ 16 ]. In addition, the most common complications reported in this survey were wound infections following colostomy creation (9.6%) and colostomy closure (12.1%), representing potential targets for quality improvement and, in select cases, avoidable morbidity when primary repair without colostomy is feasible. Overall the complication rate after posterior sagittal anorectoplasty in this survey was 27.2%, which included dehiscence (11.7%), wound infection (7.4%), and stricture (6.9%) as the most common postoperative issues. While these rates are comparable to previously published data, they emphasize the need for ongoing efforts to reduce surgical complications and improve outcomes [ 17 ]. Reported complication rates after PSARP did not significantly differ by continent or World Bank income group. In contrast, prior prospective multicenter studies have demonstrated significant differences in morbidity and mortality for gastrointestinal congenital anomalies between low-income, middle-income, and high-income countries, in a multicenter, international, prospective cohort study [ 18 ]. As such these finding should be interpreted cautiously. Survey-based complication reporting may be influenced by variation in definitions (e.g., what constitutes wound infection or stricture), documentation practices, and follow-up duration across healthcare systems, which can attenuate detectable differences. Additionally, surgeon experience and institutional case volume, factors that may strongly influence outcomes, were not directly measured in this study and may confound comparisons across regions and income categories. Future collaborative efforts incorporating prospective data capture with standardized outcome definitions and surgeon-/center-level volume metrics may better delineate true differences in postoperative morbidity. Regarding global health, while traditionally the burden of disease treatment was focused on the prevention and management of infectious disease, over the past 30 years these priorities have shifted to recognize the importance of equitable access to quality surgical care, and with it, the need for improved peri-operative care [ 19 ]. The recent Lancet-commissioned review found that 94% of people in high income countries have access to surgical care, compared to 14.9% of people in low- and middle-income countries [ 20 ]. Surgically treatable congenital anomalies represent a major source of global morbidity and mortality, with children in low- and middle-income countries (LMICs) bearing a disproportionate burden. These disparities stem from sociocultural, economic, and structural barriers that hinder access to essential and equitable pediatric surgical care [ 15 ]. When analyzing results based on geographical regions and World Bank income classifications, it becomes clear that economic factors play a significant role in the availability and implementation of best practices. Low-income and lower-middle-income countries reported fewer newborn screenings and a higher reliance on colostomy before definitive repair. This survey revealed that 50% of patients were not receiving spinal ultrasound or MRI to rule out the presence of a tethered cord, a known anomaly that may impact bowel and bladder control. This condition requires assessment and follow-up by a neurosurgeon, and in some cases may require surgical correction [ 21 ]. Importantly, diagnostic capacity does not necessarily imply therapeutic capacity. Even when spinal anomalies are identified, access to pediatric neurosurgical evaluation and operative treatment may be limited in some settings. This potential mismatch may have influenced whether screening is prioritized and highlights the need for context-specific pathways that link screening to feasible downstream care. Regardless of future treatment for tethered cord, having the diagnosis, place the patient at higher urological risk that should be known. In contrast, high-income countries were more likely to perform primary repair without colostomy and had almost universally been performing a comprehensive screening process. The question of access to diagnostic tools is brought into question when evaluating these differences, although plain films and ultrasonography are generally available to most of these centers [ 22 ]. Even with universal accessibility, sacral radiographs, recognized as a key prognostic tool for assessing future bowel control in patients with anorectal malformations, are still not routinely performed for all patients. We found that 34.2% of patients did not have a lateral sacral x-ray, important for the sacral ratio in assessing the likelihood of bowel control. Also, 21.9% of patients were missing anterior-posterior (AP) sacral X-rays, important in screening for sacral defects that may suggest a pre-sacral mass. These disparities underscore the need for targeted educational outreach and resource allocation efforts to bridge the gap in surgical care. This study has several strengths, including broad international participation, a large sample size, and a comprehensive survey design that captures perioperative practice patterns across diverse healthcare settings. Nevertheless, these findings should be interpreted in the context of several important limitations First, the retrospective nature of the survey introduces the potential for chart abstraction and reporting bias, and the absence of standardized data collection across institutions may contribute to variability in how practices and outcomes were reported. In addition, the study did not capture long-term functional outcomes, limiting the ability to directly correlate perioperative management strategies with patient prognosis. The survey also did not collect detailed information explaining why newborn screening was incomplete or why definitive repair was delayed beyond one year of age, which constrains interpretation of the underlying drivers of these findings. Second, classification by World Bank income level reflects national economic context but does not capture hospital-specific resources, referral structures, or patient-level socioeconomic factors. As a result, resource availability may be misclassified, particularly in high-income countries that serve under-resourced populations. Surgeon experience, subspecialty training, and individual case volume were also not measured and represent potential unmeasured confounders that may influence both practice patterns and outcomes. Finally, complication rates derived from survey-based data should be interpreted cautiously. Variability in complication definitions, documentation practices, follow-up duration, and reporting thresholds across institutions may limit the accuracy and comparability of reported outcomes. The absence of observed differences in complication rates across regions contrasts with findings from prospective multicenter studies demonstrating higher morbidity and mortality for congenital anomalies in low- and middle-income countries. This discrepancy likely reflects the inherent limitations of survey-based reporting rather than true equivalence in surgical outcomes or it may be related to the fact that this survey selected participants more educated and interested into colorectal conditions through their interaction with the Hendren project. Many more questions could have been included in this study, such as those regarding peri-operative antibiotics use, utilization of pre-operative bowel preparation, and length of Nil Per Os time after PSARP. A future study may be formulated now that the concept of this type of international survey has been proven to be successful. Also, future research should focus on prospective multicenter studies to further evaluate the impact of surgical and postoperative management decisions on long-term bowel function and quality of life. Conclusion This multicenter international survey demonstrates substantial variability in the perioperative management of anorectal malformations across geographic regions and World Bank income categories. Differences were identified in neonatal screening practices including sacral imaging and spinal evaluation, as well as operative strategy such as use and type of colostomy, timing of definitive repair, and postoperative management practices including anal dilation protocols. Together, these findings highlight the need for context aware quality improvement initiatives and targeted educational outreach aimed at strengthening standardized screening pathways and minimizing delays in care, while acknowledging the resource and access constraints faced by many centers worldwide. Leveraging global collaborative platforms such as The Hendren Project may enable ongoing benchmarking and the development of targeted scalable interventions to improve equity and quality of care for patients with anorectal malformations globally. Declarations Conflicts of Interest : The authors have no conflicts of interest or competing interest to declare. Funding: This research received no specific grant from funding agencies in the public, commercial, or not-for profit sectors. Author Contributions: All authors contributed to the study. VM: conceptualization, methodology, investigation, data curation, writing – original draft, writing – review and editing SAV: investigation, data curation, writing – original draft, writing – review and editing LDLT: conceptualization, methodology, writing – review and editing KEO: data curation, data analysis, writing – review and editing JK: conceptualization, investigation, data curation, writing – review and editing AP: conceptualization, methodology, writing – review and editing AB: conceptualization, methodology, writing – original draft, writing – review and editing International Surgeon Authors: investigation, writing – review and editing *Participating International Surgeon Authors Sara Ateeqa; Mohamed Farag Baayou; Adalberto Clemente Boca; Isaac Chukwu; Taiwo A. Lawal; M Oluwabukade T. Ojediran; Abdullahi Koko Nuhu; Nasiru Musa; Omebe Sunday Egwu; Obasi Akputa; Gunduz Aghayev; Muhammad Amjad Chaudhary; Mansoor Ahmed; Sadia Asmat Burki; Muhammad Arshad; Ayesha Saleem; Muhammad Ali Shiekh; Giulia Brisighelli; Hansraj Mangray; Yashlin Govender; Aws Amjad Alhamdany ; Sarmad Zuheer Aldabbah; Abouelkheir Anas; Karla Santos-Jasso; Noguez Castillo Monica; Espinosa Becerra Jorge Rafael; Bautista Martínez Maribel; Aquino Hernández Jesús Orlando; Bruno Martinez-Leo; Ambriz-González; Denisse Estefanía Alfaro Castellanos; Guillermo Yanowsky Reyes; Alfredo Domínguez-Muñoz; Emilio Fernandez-Portilla; Abhishek Kumar Singh; Kanika Sharma; Krishna Kumar Govindarajan; Enono Yhoshu; Mahendra Kumar Jangid; Nahla Kechiche; Mariem Beji; Saloua Ammar; Riadh Mhiri; Ruta Vilija Dagilyte; Gilvydas Verkauskas; Arif Oktavian; Supangat Supangat ; Ismael Essam Elhalaby; Mahmoud Elfiky; Heba Taher; Judith Lindert; Stefanie Maerzheuser; Otto Hercules; Mokrushina Olga; Morozov Dmitriy; Raphael Sun; Erica Arnold; Cortnie Vaughn; Benjamin Carr; Aodhnait S Fahy; Shauna Dowdrick; Omar Nunez Lopez; Shannon Castle; Savannah C. Walker; MD; Lindsey L. Wolf; Mathula Hettiarachchi; Shireen Anne Nah Han Yien; Don Evana Ezrien Binti Shaadon Zubir; Mirko Bertozzi; Giulia Fusi; Anna Lavinia Bulotta; Daniele Alberti; Rajendran Ramaswamy; Mutaz Ahmed; Obada Alladh Alhallaq; Lucas Koji Matsuzaki; Sylvio Gilberto Andrade Avilla; Fábio Antônio Perecim Volpe; Wellen Cristina Canesin; Joaquim Murray Bustorff-Silva; Maria Giovana Oliveira Farias; Auriane De Sousa Alencar; Ivo Lima Viana; Verónica Alonso; Marta Ortega; Laura Saura-García; Clara Massaguer Bardají; Julio César Moreno-Alfonso; Alberto Pérez Martínez; Roberto Antonio Martínez Quiroz; Luis Enrique Sanchez-Sierra; Caroll Yadira Alvarado Lemus; Brenda Mercedes Hutton; Amina G. Rasul; Serdar Moralioglu; Sabri Cansaran; Aysenur Celayir; Olga Devrim Ayvaz; Vicente Aníbal Salinas-Salinas; Jorge Alejandro Oliveros-Rivero; Tipsuda Tangsriwong; Chanel del Milagro Ugarte Coronel; Jorge Luis Mehdi Garcíam matias Berger; Ximena Breden; Celeste Patino Gonzalez; Diego Sebastian Ruarte; Luciano Sanz; José Germán Jaramillo Samaniego; Heidy Janet Tomas Huatuco; Olga Elizarova Garay Bullón; Wilbert Baca Carrasco; Dora Sandra Cárdenas Hilasaca; Hannah R. Neeser; Sasha J. Tharakan; Nebiyu Shitaye Aniley; Etsub Abebaw; Fossi Kamga gacelle; Mouafo Tambo Faustin Félicien; Elena Hanganu; Elvyn Alcantara; Zaimy Diaz; Nway Nway Thin Aung; Felix Oyania; Eunyoung Jung; Anas Shikha; Ayman A A Elhosny; A D M Shariful Islam; Osnat Zmora; Carolina Soares-Aquino; Tiago Tuna; Bourenane Haithem; Zerizer Yassine; Jorge Solarte-Henao; Luis Mauricio Figueroa-Gutierrez; Abdelrahman S. Elnour; Abdelhakam Abuelbasher Yousif Abdalla; Mohammed Haroon Ameen Basheer; Agata Dzielendziak; Dariusz Patkowski; Sage A Vincent; Vatche Melkonian; Luis de la Torre; Andrea Bischoff; Alberto Pena References Levitt MA, Peña A. Outcomes from the correction of anorectal malformations. Curr Opin Pediatr. 2005;17(3):394-401. doi:10.1097/01.mop.0000163665.36798.ac Ratan SK, Rattan KN, Pandey RM, Mittal A, Magu S, Sodhi PK. Associated congenital anomalies in patients with anorectal malformations: a need for developing a uniform practical approach. J Pediatr Surg. 2004;39(11):1706-1711. doi:10.1016/j.jpedsurg.2004.07.019 Institute of Medicine (US) Committee to Design a Strategy for Quality Review and Assurance in Medicare. Medicare: A Strategy for Quality Assurance. Volume II: Sources and Methods. Washington, DC: National Academies Press; 1990. van der Steeg HJJ, van Rooij IALM, Iacobelli BD, et al; ARM-Net Consortium. The impact of perioperative care on complications and short-term outcome in rectovestibular fistula: an ARM-Net Consortium study. J Pediatr Surg. 2019;54(8):1595-1600. doi:10.1016/j.jpedsurg.2019.03.008 McPherson K, Gon G, Scott M. International variations in a selected number of surgical procedures. OECD Health Working Papers. 2013;(61). doi:10.1787/5k49h4p5g9mw-en Driller C, Holschneider AM. Training in pediatric surgery: a comparison of 24 countries in Europe and other countries worldwide. Eur J Pediatr Surg. 2003;13(2):73-80. doi:10.1055/s-2003-39590 Whewell H, Brown C, Gokani VJ, et al; Global Surgical Training Requirements Project Collaborators. Variation in training requirements within general surgery: comparison of 23 countries. BJS Open. 2020;4(4):714-723. doi:10.1002/bjs5.50293 Meara JG, Leather AJM, Hagander L, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386(9993):569-624. doi:10.1016/S0140-6736(15)60160-X Almosallam OI, Aseeri A, Shanafey SA. Outcome of loop versus divided colostomy in the management of anorectal malformations. Ann Saudi Med. 2016;36(5):352-355. doi:10.5144/0256-4947.2016.352 Oda O, Davies D, Colapinto K, Gerstle JT. Loop versus divided colostomy for the management of anorectal malformations. J Pediatr Surg. 2014;49(1):87-90. doi:10.1016/j.jpedsurg.2013.09.032 Brisighelli G, Theron AP, Westgarth-Taylor C, et al. Are end colostomies always contraindicated in anorectal malformations? S Afr J Child Health. 2024;18(2):e1583. doi:10.7196/SAJCH.2024.v18i2.1583 Harumatsu T, Kaji T, Nagano A, et al. Early definitive operation for patients with anorectal malformation is associated with better long-term bowel function. Pediatr Surg Int. 2021;37(4):445-450. doi:10.1007/s00383-020-04842-6 Moore TC. Advantages of performing the sagittal anoplasty operation for imperforate anus at birth. J Pediatr Surg. 1990;25(2):276-277. doi:10.1016/0022-3468(90)90440-K Pelizzo G, Canonica CPM, Destro F, et al. Anorectal malformations: ideal surgery timing to reduce incontinence and optimize quality of life. Children (Basel). 2023;10(2):404. doi:10.3390/children10020404 Sitkin NA, Ozgediz D, Donkor P, Farmer DL. Congenital anomalies in low- and middle-income countries: the unborn child of global surgery. World J Surg. 2015;39(1):36-44. doi:10.1007/s00268-014-2714-9 Feng YP, Yang TS, Chung CH, et al. Early childhood general anesthesia exposure and later developmental delay: a national population-based cohort study. PLoS One. 2020;15(9):e0238289. doi:10.1371/journal.pone.0238289 Hernández Pérez A, Deltell Collomer P, Abril Sánchez C, et al. Analysis of postoperative complications in patients undergoing anorectal malformation surgery: are there any predisposing factors? Cir Pediatr. 2025;38(1):19-23. doi:10.54847/cp.2025.01.11 Global PaedSurg Research Collaboration. Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre international prospective cohort study. Lancet. 2021;398(10297):325-339. doi:10.1016/S0140-6736(21)00767-4 Santhirapala V, Peden CJ, Meara JG, et al. Towards high-quality perioperative care: a global perspective. Anaesthesia. 2020;75(suppl 1):e18-e27. doi:10.1111/anae.14921 Meara JG, Leather AJ, Hagander L, Alkire BC, Alonso N, Ameh EA, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet 2015;386(9993):569-624. Muthukumar N, Subramaniam B, Gnanaseelan T, et al. Tethered cord syndrome in children with anorectal malformations. J Neurosurg. 2000;92(4):626-630. doi:10.3171/jns.2000.92.4.0626 Ginsburg AS, Liddy Z, Khazaneh PT, et al. Barriers and facilitators to ultrasound use in low- and middle-income countries. Sci Rep. 2023;13:3322. doi:10.1038/s41598-023-30454-w Additional Declarations No competing interests reported. Supplementary Files SupplementalFiles.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 25 Apr, 2026 Reviewers agreed at journal 23 Apr, 2026 Reviews received at journal 03 Apr, 2026 Reviewers agreed at journal 24 Mar, 2026 Reviewers agreed at journal 14 Feb, 2026 Reviewers invited by journal 09 Feb, 2026 Editor assigned by journal 03 Feb, 2026 Submission checks completed at journal 03 Feb, 2026 First submitted to journal 02 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8764567","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":588205458,"identity":"d3534352-748e-4bd7-afe0-b71502a40ec3","order_by":0,"name":"Vatche Melkonian","email":"","orcid":"","institution":"Children's Hospital Colorado","correspondingAuthor":false,"prefix":"","firstName":"Vatche","middleName":"","lastName":"Melkonian","suffix":""},{"id":588205459,"identity":"c9a4051a-8e25-43ff-9e27-5e5bfbf24849","order_by":1,"name":"Sage A Vincent","email":"","orcid":"","institution":"Children's Hospital Colorado","correspondingAuthor":false,"prefix":"","firstName":"Sage","middleName":"A","lastName":"Vincent","suffix":""},{"id":588205460,"identity":"21e84c92-2ac7-4f15-b9f2-54dcbac5c455","order_by":2,"name":"Luis De La Torre","email":"","orcid":"","institution":"Children's Hospital Colorado","correspondingAuthor":false,"prefix":"","firstName":"Luis","middleName":"De La","lastName":"Torre","suffix":""},{"id":588205461,"identity":"b2d77afe-d5d2-4107-a3c6-014cc6f60de0","order_by":3,"name":"The Hendren Project Global Surgery Research Initiative","email":"","orcid":"","institution":"The Hendren Project","correspondingAuthor":false,"prefix":"","firstName":"The","middleName":"Hendren Project Global Surgery Research","lastName":"Initiative","suffix":""},{"id":588205462,"identity":"519d22d0-5cd2-4f43-9066-6ac74eef0f2a","order_by":4,"name":"Kaitlin E Olson","email":"","orcid":"","institution":"Children's Hospital Colorado","correspondingAuthor":false,"prefix":"","firstName":"Kaitlin","middleName":"E","lastName":"Olson","suffix":""},{"id":588205463,"identity":"5c5a9e04-615f-4ad4-8be5-89378f129f37","order_by":5,"name":"Jill Ketzer","email":"","orcid":"","institution":"Children's Hospital Colorado","correspondingAuthor":false,"prefix":"","firstName":"Jill","middleName":"","lastName":"Ketzer","suffix":""},{"id":588205464,"identity":"1afd2cd2-f7a6-4b62-8b9d-509f526f4266","order_by":6,"name":"Alberto Pena","email":"","orcid":"","institution":"Children's Hospital Colorado","correspondingAuthor":false,"prefix":"","firstName":"Alberto","middleName":"","lastName":"Pena","suffix":""},{"id":588205465,"identity":"ead4d312-d24a-4a94-abc1-a65866bf2ca7","order_by":7,"name":"Andrea Bischoff","email":"data:image/png;base64,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","orcid":"","institution":"Children's Hospital Colorado","correspondingAuthor":true,"prefix":"","firstName":"Andrea","middleName":"","lastName":"Bischoff","suffix":""}],"badges":[],"createdAt":"2026-02-02 11:53:36","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8764567/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8764567/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102746338,"identity":"a809681f-8867-44af-83f3-b9d0fe2ebb5f","added_by":"auto","created_at":"2026-02-16 08:56:48","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":726925,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8764567/v1/e5a26dc3-313a-40c7-b5a8-5f7468160190.pdf"},{"id":102448606,"identity":"08f0502b-0049-445e-ae99-f6ff28cb41d2","added_by":"auto","created_at":"2026-02-11 18:19:20","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":22605,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementalFiles.docx","url":"https://assets-eu.researchsquare.com/files/rs-8764567/v1/8827a956f6b0ba49f9ffbe23.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Pediatric Surgical Care of Anorectal Malformations: A Global Survey","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe successful management of anorectal malformations (ARMs) extends far beyond the primary surgical repair. While some malformations have a favorable prognosis for bowel control, inadequate perioperative care can lead to long-term complications, including fecal incontinence. Optimizing perioperative management is crucial to achieving the best functional outcomes for these patients [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In addition, comprehensive screening for associated medical conditions is essential to avoid further complications and morbidity [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe importance of delivering quality healthcare to children with anorectal malformations is essential, as the outcomes may have lifelong implications. A well-established definition of quality healthcare is \u0026ldquo;the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge\u0026rdquo; [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. A common goal shared across all pediatric surgeons is that all patients with these congenital anomalies should receive high-quality standards of care, regardless of where they are born. This includes comprehensive neonatal screening, appropriate surgical planning and technique, acceptable complication rates, and continued postoperative care [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePerioperative care for ARMs encompasses three key stages. The preoperative phase involves the timing of diagnosis, screening for associated anomalies, and determining the appropriate surgical approach, whether primary repair without colostomy, staged repair with colostomy, or delayed primary repair without colostomy. The intraoperative phase focuses on performing a technically precise operation to optimize anatomical correction and functional outcomes. The postoperative phase variably includes anal dilations to prevent stricture formation and bowel management strategies to address constipation and fecal incontinence [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Despite the availability of established perioperative guidelines, significant variations in practice exist worldwide [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Barriers to this goal may come from variations of clinical practice, both in the United States and internationally, secondary to differences in national culture, medical education, residency/fellowship training, health beliefs, and longstanding traditions [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR27\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite broad recognition that resource availability influences surgical care globally, there are limited data describing how these differences manifest in the perioperative management of anorectal malformations at the level of day-to-day surgical decision-making. Existing global surgery studies often focus on mortality or access to surgery, rather than specific diagnostic and perioperative processes that are potentially modifiable [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Leveraging The Hendren Project, a global collaborative network of pediatric surgeons, provides a unique opportunity to benchmark current practices across diverse healthcare systems using a standardized framework. By identifying areas of consistent practice alongside modifiable gaps, this study aims to generate actionable targets for education, quality improvement, and future collaborative initiatives rather than merely describing resource disparities.\u003c/p\u003e \u003cp\u003eOur objective was to examine the management of anorectal malformations by pediatric surgeons worldwide, assessing areas of consensus and variability regarding perioperative care, while also reviewing reported outcomes. By highlighting differences in practice, this study aims to inform future educational outreach efforts and quality improvement initiatives in an attempt to decrease surgical care disparity for these patients, regardless of geographic location. We hypothesized that substantial variation would exist in patient care at both the institutional and continental levels.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Setting\u003c/h2\u003e \u003cp\u003eA survey was distributed electronically through The Hendren Project, a global networked community of pediatric surgeons and urologists, on March 15th, 2024. Surgeons could participate by retrospectively reviewing the past ten patients who underwent reconstruction for anorectal malformations at their institution. Only primary cases, no reoperations, could be included. Each author was responsible for obtaining the necessary local approvals from their ethical review boards. Given the relative rarity of ARMs, ten cases were felt to be a representative sample of cases.\u003c/p\u003e \u003cp\u003eThe Hendren Project was selected as the distribution platform because it is an established international network of pediatric surgeons with a mission aligned to collaborative benchmarking and dissemination of best practices. Its global reach enabled participation from a broad range of healthcare systems using a standardized survey instrument.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Population\u003c/h3\u003e\n\u003cp\u003eAlthough the total number of Hendren Project members receiving the survey invitation was known, eligibility required completion of at least ten primary ARM repairs, and this denominator could not be verified. As such, a formal response rate could not be calculated. However, participating surgeons represented 90 hospitals across 50 countries and five continents, providing broad geographic representation.\u003c/p\u003e \u003cp\u003eParticipants were provided with a consent form explaining the purpose, benefits, and possible risks of enrolling in the survey. The survey post-card containing the link read as follows: \u0026ldquo;If your current center has completed at least ten primary operations to repair any anorectal malformation, you have obtained any necessary regulatory approvals, and you wish to participate in this study, please complete this survey\u0026rdquo;.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eParticipation included the opportunity for up to two contributing surgeons per institution to be listed as co-authors for their contribution to the data collection. Authorship was not intended as an incentive, but was intended to reflect the work required to obtain ethical permissions and review patient data. The survey was conducted securely in Qualtrics. In addition to this, the survey asked for the surgeon\u0026rsquo;s city, country, and hospital. At no time was any identifying information requested about the ten reported patient cases.\u003c/p\u003e \u003cp\u003eThe survey proceeded with a repeating cycle of up to 16 multiple-choice questions, some of which would auto-populate depending on the previous answer. This would cycle through ten times before the survey was considered completed to receive information on all ten unique patients. Many of the questions also had the option to submit a further explanation, for example, if the choice of \u0026ldquo;other\u0026rdquo; was selected. Survey questions can be found in the appendix. To minimize duplicate institutional submissions, survey responses were linked to the institution name, and duplicate entries from the same center were reconciled during data cleaning. A copy of survey questions can be seen in Supplemental Fig.\u0026nbsp;1.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eData was analyzed at the patient level and at the hospital level. At the patient level, categorical variables are presented as frequency and percent. At the hospital level, the data was broken up into five continents: Africa, Asia (including Australia), Europe, North America, and South America. Continents and countries were subdivided into World Bank Income classes: low/low-middle, upper-middle, and high. This classification system has been previously used in the global health literature [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Hospital level variables were created by aggregating patient-level data within a hospital and presented as percentages. For each variable, within each hospital or each row, the number of records that indicated \u0026ldquo;yes\u0026rdquo; for a variable was summed and divided by the total number of patients with responses to that variable and converted to a percentage. These numeric variables were summarized using frequency, and median (interquartile range), as appropriate.\u003c/p\u003e \u003cp\u003eComparisons between continents and World Bank Income classes were made using Kruskal-Wallis test, adjusting for the non-normality of the distribution. The significance level was assumed to be α\u0026thinsp;=\u0026thinsp;0.05. R version 4.4.2 was utilized for all statistical analyses.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthical Considerations\u003c/h3\u003e\n\u003cp\u003eThe coordinating institution obtained IRB approval (COMIRB No: 24\u0026ndash;0202). Participating centers were instructed to obtain local IRB approval or a waiver in accordance with institutional and national regulations; documentation was not centrally verified.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eFor this survey, 144 surgeons responded from 90 hospitals in 50 different countries, reporting 900 patients. A response rate is not able to be captured due to changing listservs and variations in email deliverability. The sub-type of anorectal malformation as well as the summary of newborn screenings and approach to repair can be seen in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Sacral radiographs, widely available and recognized as a key prognostic tool for assessing future bowel control in patients with anorectal malformations, are still not routinely performed for all patients, with 34.2% lacking lateral views and 21.9% missing anterior-posterior (AP) views. The complication rate after PSARP was 27.2%, with the most common being dehiscence (11.7%), wound infection (7.4%), and stricture (6.9%). Post-operative anal dilations were performed by 92.6% of surgeons (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of patient anorectal malformation subtype, newborn screening and approach to repair reported in a global survey of pediatric surgeons.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll Patients (n\u0026thinsp;=\u0026thinsp;900)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAnorectal Malformation, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecto-perineal fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e238 (26.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecto-vestibular fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e219 (24.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecto-urethral bulbar fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e109 (12.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecto-urethral prostatic fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69 (7.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecto-bladder neck fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42 (4.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecto-vaginal fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (3.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e99 (11.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCloaca\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62 (6.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (3.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eNewborn screening, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSacral radiograph AP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e684 (78.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSacral radiograph lateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e576 (65.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRenal ultrasound\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e790 (90.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpinal ultrasound/MRI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e440 (50.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePelvic ultrasound\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54/62 (87.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEchocardiogram\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e708 (80.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSurgical Repair\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAge at time of primary repair, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;6 months of age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e336 (37.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6 months to 1 year of age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e283 (31.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 to 2 years of age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e176 (19.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2 to 3 years of age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49 (5.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;3 years of age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47 (5.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eColostomy created during newborn period, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e563 (62.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eColostomy during primary repair, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e599 (67.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eComplications following primary repair, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDehiscence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e104 (11.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66 (7.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStricture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61 (6.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProlapse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39 (4.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeed for reoperation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43 (4.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMortality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (0.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e648 (72.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUse of postoperative anal dilations, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e826 (92.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e(AP- anterior posterior; MRI- magnetic resonance imaging)\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e\u003csup\u003ea\u003c/sup\u003eIn some circumstances, survey respondents omitted answers to some questions, as such not all categories summate to reported totals\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003csup\u003eb\u003c/sup\u003ePelvic ultrasound question only asked when the patient\u0026rsquo;s ARM pathology was cloaca.\u003c/p\u003e \u003cp\u003eColostomy creation was done at less than six months in age in 84.8% of patients, with a small minority undergoing delayed colostomy (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). There were more responses to the colostomy creation and closure question (n\u0026thinsp;=\u0026thinsp;621) than colostomy present during primary repair (n\u0026thinsp;=\u0026thinsp;599), indicating that some patients underwent colostomy outside of the primary repair, as in the case of a complication. Surgeons reported more frequent use of divided stoma (66.3%) compared to loop (28.8%). Complications after colostomy creation occurred in 18% of patients, most frequently wound infection, followed by need for reoperation. Colostomy closure was performed between six months to two years of age in 70% of reported patients (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Complications occurred in 15% of patients following their colostomy closure, most commonly wound infection (12.1%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of timing, technique, and complication rate associated with colostomy creation and closure for pediatric patients with anorectal malformations, as reported by a global survey of pediatric surgeons.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll Patients (n\u0026thinsp;=\u0026thinsp;621)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eColostomy creation\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAge at colostomy creation, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;6 months of age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e503 (84.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6 months to 1 year of age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43 (7.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 to 2 years of age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (4.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2 to 3 years of age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (1.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;3 years of age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (2.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eType of colostomy created, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDivided/end\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e406 (66.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLoop\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e176 (28.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHartmann pouch\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (1.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (3.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eComplications following colostomy creation, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDehiscence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (5.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59 (9.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStricture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (3.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeed for reoperation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (6.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMortality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e503 (81.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eColostomy closure\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAge at colostomy closure, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;6 months of age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39 (6.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6 months to 1 year of age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e185 (31.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 to 2 years of age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e238 (40.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2 to 3 years of age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68 (11.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;3 years of age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62 (10.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eComplications following colostomy closure, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDehiscence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (3.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71 (12.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStricture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (1.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHernia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (1.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeed for reoperation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (2.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMortality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e496 (84.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e\u003csup\u003ea\u003c/sup\u003eIn some circumstances, survey respondents omitted answers to some questions, as such not all categories summate to reported totals\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThere was a significant difference in the distribution of World Bank Income Levels when stratifying by continent (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The majority of hospitals reporting in Africa and Asia were classified as low/lower-middle income (77.3% and 52.4%, respectively). In North America, 50% of hospitals were classified as upper-middle income, while 92.3% of hospitals in South America were classified as the same. Europe, meanwhile, had a significant proportion of hospitals categorized as high income (85.7%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFrequency of hospital classification by World Bank Income Level summarized by continent of practicing pediatric surgeons responding to a global survey about anorectal malformation management.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAfrica (n\u0026thinsp;=\u0026thinsp;22)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAsia (n\u0026thinsp;=\u0026thinsp;21)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEurope (n\u0026thinsp;=\u0026thinsp;14)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNorth America (n\u0026thinsp;=\u0026thinsp;18)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSouth America (n\u0026thinsp;=\u0026thinsp;14)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eWorld Bank Income Level, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow/lower-middle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17 (77.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11 (52.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2 (11.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1/13 (7.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUpper-middle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (22.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (23.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2 (14.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9 (50.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e12/13 (92.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (23.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12 (85.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7 (38.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0/13 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003csup\u003ea\u003c/sup\u003eSouth America is represented by surgeon respondents from 14 countries, one of which is Venezuela. Venezuela\u0026rsquo;s World Bank Income Level is \u0026ldquo;Not Classified\u0026rdquo;, and as such, was removed from frequency calculations.\u003c/p\u003e \u003cp\u003eThe median percentage of patients who underwent sacral radiograph (AP and lateral), spinal ultrasound or spinal MRI, and echocardiogram as part of their screening work up for associated anomalies different significantly by World Bank Income Level (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Spinal ultrasound was performed more frequently in upper-middle and high groups (55% and 100% vs 0%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Echocardiogram was also more frequently performed in the upper-middle and high groups than low/lower-middle (100% and 100% vs 70%, p\u0026thinsp;=\u0026thinsp;0.002). There was no difference in the frequency of screening with renal ultrasound or pelvic ultrasound (in the case of cloaca patients).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of newborn anomaly screening modalities performed for patients with anorectal malformations by the World Bank Income Level classification of the hospital, as reported by responding pediatric surgeons to a global survey.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow/lower-middle\u003csup\u003ea\u003c/sup\u003e (n\u0026thinsp;=\u0026thinsp;31)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUpper-middle\u003csup\u003ea\u003c/sup\u003e (n\u0026thinsp;=\u0026thinsp;34)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHigh\u003csup\u003ea\u003c/sup\u003e (n\u0026thinsp;=\u0026thinsp;24)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eImaging modality, \u003cem\u003emedian percentage (IQR)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSacral radiograph (AP)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90 (15, 100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100 (100, 100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95 (17.8, 100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.005\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSacral radiograph (lateral)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70 (20, 90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100 (72.5, 100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25 (0, 100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRenal ultrasound\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100 (80, 100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100 (100, 100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100 (90, 100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.407\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpinal ultrasound/MRI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0, 30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55 (11.4, 100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100 (73.9, 100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePelvic ultrasound\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0, 0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0, 10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0, 10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.995\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEchocardiogram\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70 (40, 100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100 (90, 100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100 (100, 100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e(IQR- interquartile range; AP- anterior posterior; MRI- magnetic resonance imaging)\u003c/p\u003e \u003cp\u003e \u003csup\u003ea\u003c/sup\u003eVenezuela\u0026rsquo;s World Bank Income Level is \u0026ldquo;Not Classified\u0026rdquo;, and as such, any hospitals in Venezuela were removed from this analysis.\u003c/p\u003e \u003cp\u003e \u003csup\u003eb\u003c/sup\u003ePelvic ultrasound question only asked when the patient\u0026rsquo;s ARM pathology was cloaca.\u003c/p\u003e \u003cp\u003eWith regards to primary ARM repair, the median percentage of patients who underwent colostomy creation during newborn period and during primary repair was significantly different between the different Work Bank Income Levels (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). The age at time of primary repair was also significantly different by World Bank Income Level for all age subgroups, except 6 months to 1 year of age.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of operative repair timing, approach, and complications for patients with anorectal malformations by the World Bank Income Level classification of the hospital, as reported by responding pediatric surgeons to a global survey.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow/lower-middle\u003csup\u003ea\u003c/sup\u003e (n\u0026thinsp;=\u0026thinsp;31)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUpper-middle\u003csup\u003ea\u003c/sup\u003e (n\u0026thinsp;=\u0026thinsp;34)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHigh\u003csup\u003ea\u003c/sup\u003e (n\u0026thinsp;=\u0026thinsp;24)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eSurgical repair, \u003cem\u003emedian percentage (IQR)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eColostomy created during newborn period\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70 (55, 80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70 (60, 89.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50 (37.5, 60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eColostomy created during primary repair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70 (60, 100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80 (60, 90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50 (40, 60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUse of postoperative anal dilations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90 (90, 90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90 (86.8, 90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e90 (80, 90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.245\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eAge at time of primary repair, \u003cem\u003emedian percentage (IQR)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;6 months of age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (10, 40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (10, 48.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e60 (47.5, 72.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6 months to 1 year of age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (20, 40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (10, 50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21 (10, 40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.502\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 to 2 years of age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (10, 30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (10, 32.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (0, 20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.036\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2 to 3 years of age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0, 10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0, 10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0, 0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.041\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;3 years of age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0, 5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0, 10.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0, 0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.006\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e(IQR- interquartile range; AP- anterior posterior; MRI- magnetic resonance imaging)\u003c/p\u003e \u003cp\u003e \u003csup\u003ea\u003c/sup\u003eVenezuela\u0026rsquo;s World Bank Income Level is \u0026ldquo;Not Classified\u0026rdquo;, and as such, any hospitals in Venezuela were removed from this analysis.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study provides a comprehensive analysis of global practices in the management of anorectal malformations (ARMs), highlighting areas of consensus and variability among pediatric surgeons. The findings underscore significant disparities in perioperative care, influenced by geographical location, healthcare infrastructure, and access to resources. These variations are particularly evident in the use of sacral radiographs, surgical techniques, and postoperative management strategies, all of which have implications for long-term functional outcomes in children with ARMs.\u003c/p\u003e \u003cp\u003eWe observed regional differences in the proportion of recto-perineal fistulas. This finding may reflect differences in referral patterns (e.g., complex malformations preferentially referred to specialty centers), regional variation in diagnostic classification practices, or survivorship and access effects in which more complex malformations may be underrepresented in settings with delayed presentation or limited access to neonatal surgical care. Because this study relied on retrospective sampling of recent institutional cases without external verification, we cannot determine whether these differences represent true epidemiologic variation versus ascertainment or classification differences.\u003c/p\u003e \u003cp\u003eSurgical techniques for ARM repair also vary widely, particularly in the approach to colostomy creation. The majority of surgeons in this study reported performing divided colostomies (66.3%) while other surgeons reported the preference for loop colostomies (28.8%). Traditional teaching has supported divided colostomies over the loop colostomy to decrease the incidence of urinary tract infections, although recent studies have suggested a similar incidence of complications with the use of either method [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. One study did however suggest an increased risk of prolapse with loop colostomies [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOf note, the goal of colostomy creation for patients with ARMs is to divert the fecal stream, avoid potential urinary tract infection, and allow for a future high-pressure distal colostogram to define the anatomy pre-operatively. However, in select cases where patients have an opening in their perineum, such as with a perineal fistula or rectovestibular fistula, an end colostomy and Hartmann\u0026rsquo;s pouch could be considered [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The risk to this approach is in the event of a dehiscence, retraction, or acquired atresia after a PSARP, this would result in a blind segment of bowel, with no point of egress.\u003c/p\u003e \u003cp\u003eAnother significant finding of this survey was delayed timing of definitive surgical repair. Overall, 30.6% of patients did not undergo repair until after one year of age, and 62.4% were repaired after six months of age. These findings are notable given the well-documented advantages of early anorectoplasty, which include the potential to avoid colostomy, reduce the total number of operations, and optimize long-term bowel function. Harumatsu et al. demonstrated superior long-term bowel outcomes among patients undergoing early repair (\u0026lt;\u0026thinsp;5 months) compared with those repaired later (\u0026gt;\u0026thinsp;5 months) [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Additional studies support these findings, suggesting that earlier repair may maximize development of defecation reflexes and is associated with improved continence and quality of life\u0026mdash;particularly when repair is performed before three months of age for non-complex malformations and within the first year of life for more complex anomalies [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough delayed repair was common in this cohort, the survey was designed to capture institutional practice patterns rather than the clinical reasoning underlying individual cases. As such, follow-up queries were not performed to clarify surgeon-specific decision thresholds, including reasons for delaying repair beyond one year or selecting staged versus primary repair. Future iterations of this survey should incorporate targeted questions addressing factors that influence timing decisions, such as referral delays, neonatal intensive care unit capacity, anesthesia availability, access to contrast studies, surgeon availability, and family travel constraints.\u003c/p\u003e \u003cp\u003eImportantly, variability in age at repair and completeness of newborn screening appeared closely linked to resource setting. Centers in lower-income regions more frequently reported delayed repair and incomplete screening, likely reflecting challenges related to early diagnosis, referral pathways, diagnostic imaging access, anesthesia availability, and competing health system priorities. These differences do not necessarily represent deviations from best practice but rather reflect structural constraints that shape what care delivery is feasible in different settings [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWithin this context, the decision to create a colostomy prior to definitive repair warrants careful consideration. While colostomy remains an appropriate and often necessary component of ARM management, it commits patients to multiple operations\u0026mdash;colostomy creation, posterior sagittal anorectoplasty, and colostomy closure\u0026mdash;each requiring exposure to general anesthesia. Emerging data have raised concerns regarding early childhood anesthesia exposure and potential associations with neurodevelopmental delay in children under two years of age [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In addition, the most common complications reported in this survey were wound infections following colostomy creation (9.6%) and colostomy closure (12.1%), representing potential targets for quality improvement and, in select cases, avoidable morbidity when primary repair without colostomy is feasible.\u003c/p\u003e \u003cp\u003eOverall the complication rate after posterior sagittal anorectoplasty in this survey was 27.2%, which included dehiscence (11.7%), wound infection (7.4%), and stricture (6.9%) as the most common postoperative issues. While these rates are comparable to previously published data, they emphasize the need for ongoing efforts to reduce surgical complications and improve outcomes [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Reported complication rates after PSARP did not significantly differ by continent or World Bank income group. In contrast, prior prospective multicenter studies have demonstrated significant differences in morbidity and mortality for gastrointestinal congenital anomalies between low-income, middle-income, and high-income countries, in a multicenter, international, prospective cohort study [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAs such these finding should be interpreted cautiously. Survey-based complication reporting may be influenced by variation in definitions (e.g., what constitutes wound infection or stricture), documentation practices, and follow-up duration across healthcare systems, which can attenuate detectable differences. Additionally, surgeon experience and institutional case volume, factors that may strongly influence outcomes, were not directly measured in this study and may confound comparisons across regions and income categories. Future collaborative efforts incorporating prospective data capture with standardized outcome definitions and surgeon-/center-level volume metrics may better delineate true differences in postoperative morbidity.\u003c/p\u003e \u003cp\u003eRegarding global health, while traditionally the burden of disease treatment was focused on the prevention and management of infectious disease, over the past 30 years these priorities have shifted to recognize the importance of equitable access to quality surgical care, and with it, the need for improved peri-operative care [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The recent Lancet-commissioned review found that 94% of people in high income countries have access to surgical care, compared to 14.9% of people in low- and middle-income countries [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Surgically treatable congenital anomalies represent a major source of global morbidity and mortality, with children in low- and middle-income countries (LMICs) bearing a disproportionate burden. These disparities stem from sociocultural, economic, and structural barriers that hinder access to essential and equitable pediatric surgical care [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhen analyzing results based on geographical regions and World Bank income classifications, it becomes clear that economic factors play a significant role in the availability and implementation of best practices. Low-income and lower-middle-income countries reported fewer newborn screenings and a higher reliance on colostomy before definitive repair. This survey revealed that 50% of patients were not receiving spinal ultrasound or MRI to rule out the presence of a tethered cord, a known anomaly that may impact bowel and bladder control. This condition requires assessment and follow-up by a neurosurgeon, and in some cases may require surgical correction [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Importantly, diagnostic capacity does not necessarily imply therapeutic capacity. Even when spinal anomalies are identified, access to pediatric neurosurgical evaluation and operative treatment may be limited in some settings. This potential mismatch may have influenced whether screening is prioritized and highlights the need for context-specific pathways that link screening to feasible downstream care. Regardless of future treatment for tethered cord, having the diagnosis, place the patient at higher urological risk that should be known.\u003c/p\u003e \u003cp\u003eIn contrast, high-income countries were more likely to perform primary repair without colostomy and had almost universally been performing a comprehensive screening process. The question of access to diagnostic tools is brought into question when evaluating these differences, although plain films and ultrasonography are generally available to most of these centers [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Even with universal accessibility, sacral radiographs, recognized as a key prognostic tool for assessing future bowel control in patients with anorectal malformations, are still not routinely performed for all patients. We found that 34.2% of patients did not have a lateral sacral x-ray, important for the sacral ratio in assessing the likelihood of bowel control. Also, 21.9% of patients were missing anterior-posterior (AP) sacral X-rays, important in screening for sacral defects that may suggest a pre-sacral mass. These disparities underscore the need for targeted educational outreach and resource allocation efforts to bridge the gap in surgical care.\u003c/p\u003e \u003cp\u003e This study has several strengths, including broad international participation, a large sample size, and a comprehensive survey design that captures perioperative practice patterns across diverse healthcare settings. Nevertheless, these findings should be interpreted in the context of several important limitations\u003c/p\u003e \u003cp\u003eFirst, the retrospective nature of the survey introduces the potential for chart abstraction and reporting bias, and the absence of standardized data collection across institutions may contribute to variability in how practices and outcomes were reported. In addition, the study did not capture long-term functional outcomes, limiting the ability to directly correlate perioperative management strategies with patient prognosis. The survey also did not collect detailed information explaining why newborn screening was incomplete or why definitive repair was delayed beyond one year of age, which constrains interpretation of the underlying drivers of these findings.\u003c/p\u003e \u003cp\u003eSecond, classification by World Bank income level reflects national economic context but does not capture hospital-specific resources, referral structures, or patient-level socioeconomic factors. As a result, resource availability may be misclassified, particularly in high-income countries that serve under-resourced populations. Surgeon experience, subspecialty training, and individual case volume were also not measured and represent potential unmeasured confounders that may influence both practice patterns and outcomes.\u003c/p\u003e \u003cp\u003eFinally, complication rates derived from survey-based data should be interpreted cautiously. Variability in complication definitions, documentation practices, follow-up duration, and reporting thresholds across institutions may limit the accuracy and comparability of reported outcomes. The absence of observed differences in complication rates across regions contrasts with findings from prospective multicenter studies demonstrating higher morbidity and mortality for congenital anomalies in low- and middle-income countries. This discrepancy likely reflects the inherent limitations of survey-based reporting rather than true equivalence in surgical outcomes or it may be related to the fact that this survey selected participants more educated and interested into colorectal conditions through their interaction with the Hendren project.\u003c/p\u003e \u003cp\u003eMany more questions could have been included in this study, such as those regarding peri-operative antibiotics use, utilization of pre-operative bowel preparation, and length of Nil Per Os time after PSARP. A future study may be formulated now that the concept of this type of international survey has been proven to be successful. Also, future research should focus on prospective multicenter studies to further evaluate the impact of surgical and postoperative management decisions on long-term bowel function and quality of life.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis multicenter international survey demonstrates substantial variability in the perioperative management of anorectal malformations across geographic regions and World Bank income categories. Differences were identified in neonatal screening practices including sacral imaging and spinal evaluation, as well as operative strategy such as use and type of colostomy, timing of definitive repair, and postoperative management practices including anal dilation protocols. Together, these findings highlight the need for context aware quality improvement initiatives and targeted educational outreach aimed at strengthening standardized screening pathways and minimizing delays in care, while acknowledging the resource and access constraints faced by many centers worldwide. Leveraging global collaborative platforms such as The Hendren Project may enable ongoing benchmarking and the development of targeted scalable interventions to improve equity and quality of care for patients with anorectal malformations globally.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflicts of Interest\u003c/strong\u003e: The authors have no conflicts of interest or competing interest to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This research received no specific grant from funding agencies in the public, commercial, or not-for profit sectors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eVM: conceptualization, methodology, investigation, data curation, writing \u0026ndash; original draft, writing \u0026ndash; review and editing\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSAV: investigation, data curation, writing \u0026ndash; original draft, writing \u0026ndash; review and editing\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLDLT: conceptualization, methodology, writing \u0026ndash; review and editing\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eKEO: data curation, data analysis, writing \u0026ndash; review and editing\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eJK: conceptualization, investigation, data curation, writing \u0026ndash; review and editing\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAP: conceptualization, methodology, writing \u0026ndash; review and editing\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAB: conceptualization, methodology, writing \u0026ndash; original draft, writing \u0026ndash; review and editing\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInternational Surgeon Authors: investigation, writing \u0026ndash; review and editing\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e*Participating International Surgeon Authors\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eSara Ateeqa; Mohamed Farag Baayou; Adalberto Clemente Boca; Isaac Chukwu; Taiwo A. Lawal; M Oluwabukade T. Ojediran; Abdullahi Koko Nuhu; Nasiru Musa; Omebe Sunday Egwu; Obasi Akputa; Gunduz Aghayev; Muhammad Amjad Chaudhary; Mansoor Ahmed; Sadia Asmat Burki; Muhammad Arshad; Ayesha Saleem; Muhammad Ali Shiekh; Giulia Brisighelli; Hansraj Mangray; Yashlin Govender; Aws Amjad Alhamdany ; Sarmad Zuheer Aldabbah; Abouelkheir Anas; Karla Santos-Jasso; Noguez Castillo Monica; Espinosa Becerra Jorge Rafael; Bautista Mart\u0026iacute;nez Maribel; Aquino Hern\u0026aacute;ndez Jes\u0026uacute;s Orlando; Bruno Martinez-Leo; Ambriz-Gonz\u0026aacute;lez; Denisse Estefan\u0026iacute;a Alfaro Castellanos; Guillermo Yanowsky Reyes; Alfredo Dom\u0026iacute;nguez-Mu\u0026ntilde;oz; Emilio Fernandez-Portilla; Abhishek Kumar Singh; Kanika Sharma; Krishna Kumar Govindarajan; Enono Yhoshu; Mahendra Kumar Jangid; Nahla Kechiche; Mariem Beji; Saloua Ammar; Riadh Mhiri; Ruta Vilija Dagilyte; Gilvydas Verkauskas; Arif Oktavian; Supangat Supangat ; Ismael Essam Elhalaby; Mahmoud Elfiky; Heba Taher; Judith Lindert; Stefanie Maerzheuser; Otto Hercules; Mokrushina Olga; Morozov Dmitriy; Raphael Sun; Erica Arnold; Cortnie Vaughn; Benjamin Carr; Aodhnait S Fahy; Shauna Dowdrick; Omar Nunez Lopez; Shannon Castle; Savannah C. Walker; MD; Lindsey L. Wolf; Mathula Hettiarachchi; Shireen Anne Nah Han Yien; Don Evana Ezrien Binti Shaadon Zubir; Mirko Bertozzi; Giulia Fusi; Anna Lavinia Bulotta; Daniele Alberti; Rajendran Ramaswamy; Mutaz Ahmed; Obada Alladh Alhallaq; Lucas Koji Matsuzaki; Sylvio Gilberto Andrade Avilla; F\u0026aacute;bio Ant\u0026ocirc;nio Perecim Volpe; Wellen Cristina Canesin; Joaquim Murray Bustorff-Silva; Maria Giovana Oliveira Farias; Auriane De Sousa Alencar; Ivo Lima Viana; Ver\u0026oacute;nica Alonso; Marta Ortega; Laura Saura-Garc\u0026iacute;a; Clara Massaguer Bardaj\u0026iacute;; Julio C\u0026eacute;sar Moreno-Alfonso; Alberto P\u0026eacute;rez Mart\u0026iacute;nez; Roberto Antonio Mart\u0026iacute;nez Quiroz; Luis Enrique Sanchez-Sierra; Caroll Yadira Alvarado Lemus; Brenda Mercedes Hutton; Amina G. Rasul; Serdar Moralioglu; Sabri Cansaran; Aysenur Celayir; Olga Devrim Ayvaz; Vicente An\u0026iacute;bal Salinas-Salinas; Jorge Alejandro Oliveros-Rivero; Tipsuda Tangsriwong; Chanel del Milagro Ugarte Coronel; Jorge Luis Mehdi Garc\u0026iacute;am matias Berger; Ximena Breden; Celeste Patino Gonzalez; Diego Sebastian Ruarte; Luciano Sanz; Jos\u0026eacute; Germ\u0026aacute;n Jaramillo Samaniego; Heidy Janet Tomas Huatuco; Olga Elizarova Garay Bull\u0026oacute;n; Wilbert Baca Carrasco; Dora Sandra C\u0026aacute;rdenas Hilasaca; Hannah R. Neeser; Sasha J. Tharakan; Nebiyu Shitaye Aniley; Etsub Abebaw; Fossi Kamga gacelle; Mouafo Tambo Faustin F\u0026eacute;licien; Elena Hanganu; Elvyn Alcantara; Zaimy Diaz; Nway Nway Thin Aung; Felix Oyania; Eunyoung Jung; Anas Shikha; Ayman A A Elhosny; A D M Shariful Islam; Osnat Zmora; Carolina Soares-Aquino; Tiago Tuna; Bourenane Haithem; Zerizer Yassine; Jorge Solarte-Henao; Luis Mauricio Figueroa-Gutierrez; Abdelrahman S. Elnour; Abdelhakam Abuelbasher Yousif Abdalla; Mohammed Haroon Ameen Basheer; Agata Dzielendziak; Dariusz Patkowski; Sage A Vincent; Vatche Melkonian; Luis de la Torre; Andrea Bischoff; Alberto Pena\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLevitt MA, Pe\u0026ntilde;a A. Outcomes from the correction of anorectal malformations. Curr Opin Pediatr. 2005;17(3):394-401. doi:10.1097/01.mop.0000163665.36798.ac\u003c/li\u003e\n\u003cli\u003eRatan SK, Rattan KN, Pandey RM, Mittal A, Magu S, Sodhi PK. Associated congenital anomalies in patients with anorectal malformations: a need for developing a uniform practical approach. J Pediatr Surg. 2004;39(11):1706-1711. doi:10.1016/j.jpedsurg.2004.07.019\u003c/li\u003e\n\u003cli\u003eInstitute of Medicine (US) Committee to Design a Strategy for Quality Review and Assurance in Medicare. Medicare: A Strategy for Quality Assurance. Volume II: Sources and Methods. Washington, DC: National Academies Press; 1990.\u003c/li\u003e\n\u003cli\u003evan der Steeg HJJ, van Rooij IALM, Iacobelli BD, et al; ARM-Net Consortium. The impact of perioperative care on complications and short-term outcome in rectovestibular fistula: an ARM-Net Consortium study. J Pediatr Surg. 2019;54(8):1595-1600. doi:10.1016/j.jpedsurg.2019.03.008\u003c/li\u003e\n\u003cli\u003eMcPherson K, Gon G, Scott M. International variations in a selected number of surgical procedures. OECD Health Working Papers. 2013;(61). doi:10.1787/5k49h4p5g9mw-en\u003c/li\u003e\n\u003cli\u003eDriller C, Holschneider AM. Training in pediatric surgery: a comparison of 24 countries in Europe and other countries worldwide. Eur J Pediatr Surg. 2003;13(2):73-80. doi:10.1055/s-2003-39590\u003c/li\u003e\n\u003cli\u003eWhewell H, Brown C, Gokani VJ, et al; Global Surgical Training Requirements Project Collaborators. Variation in training requirements within general surgery: comparison of 23 countries. BJS Open. 2020;4(4):714-723. doi:10.1002/bjs5.50293\u003c/li\u003e\n\u003cli\u003eMeara JG, Leather AJM, Hagander L, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386(9993):569-624. doi:10.1016/S0140-6736(15)60160-X\u003c/li\u003e\n\u003cli\u003eAlmosallam OI, Aseeri A, Shanafey SA. Outcome of loop versus divided colostomy in the management of anorectal malformations. Ann Saudi Med. 2016;36(5):352-355. doi:10.5144/0256-4947.2016.352\u003c/li\u003e\n\u003cli\u003eOda O, Davies D, Colapinto K, Gerstle JT. Loop versus divided colostomy for the management of anorectal malformations. J Pediatr Surg. 2014;49(1):87-90. doi:10.1016/j.jpedsurg.2013.09.032\u003c/li\u003e\n\u003cli\u003eBrisighelli G, Theron AP, Westgarth-Taylor C, et al. Are end colostomies always contraindicated in anorectal malformations? S Afr J Child Health. 2024;18(2):e1583. doi:10.7196/SAJCH.2024.v18i2.1583\u003c/li\u003e\n\u003cli\u003eHarumatsu T, Kaji T, Nagano A, et al. Early definitive operation for patients with anorectal malformation is associated with better long-term bowel function. Pediatr Surg Int. 2021;37(4):445-450. doi:10.1007/s00383-020-04842-6\u003c/li\u003e\n\u003cli\u003eMoore TC. Advantages of performing the sagittal anoplasty operation for imperforate anus at birth. J Pediatr Surg. 1990;25(2):276-277. doi:10.1016/0022-3468(90)90440-K\u003c/li\u003e\n\u003cli\u003ePelizzo G, Canonica CPM, Destro F, et al. Anorectal malformations: ideal surgery timing to reduce incontinence and optimize quality of life. Children (Basel). 2023;10(2):404. doi:10.3390/children10020404\u003c/li\u003e\n\u003cli\u003eSitkin NA, Ozgediz D, Donkor P, Farmer DL. Congenital anomalies in low- and middle-income countries: the unborn child of global surgery. World J Surg. 2015;39(1):36-44. doi:10.1007/s00268-014-2714-9\u003c/li\u003e\n\u003cli\u003eFeng YP, Yang TS, Chung CH, et al. Early childhood general anesthesia exposure and later developmental delay: a national population-based cohort study. PLoS One. 2020;15(9):e0238289. doi:10.1371/journal.pone.0238289\u003c/li\u003e\n\u003cli\u003eHern\u0026aacute;ndez P\u0026eacute;rez A, Deltell Collomer P, Abril S\u0026aacute;nchez C, et al. Analysis of postoperative complications in patients undergoing anorectal malformation surgery: are there any predisposing factors? Cir Pediatr. 2025;38(1):19-23. doi:10.54847/cp.2025.01.11\u003c/li\u003e\n\u003cli\u003eGlobal PaedSurg Research Collaboration. Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre international prospective cohort study. Lancet. 2021;398(10297):325-339. doi:10.1016/S0140-6736(21)00767-4\u003c/li\u003e\n\u003cli\u003eSanthirapala V, Peden CJ, Meara JG, et al. Towards high-quality perioperative care: a global perspective. Anaesthesia. 2020;75(suppl 1):e18-e27. doi:10.1111/anae.14921\u003c/li\u003e\n\u003cli\u003eMeara JG, Leather AJ, Hagander L, Alkire BC, Alonso N, Ameh EA, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet 2015;386(9993):569-624.\u003c/li\u003e\n\u003cli\u003eMuthukumar N, Subramaniam B, Gnanaseelan T, et al. Tethered cord syndrome in children with anorectal malformations. J Neurosurg. 2000;92(4):626-630. doi:10.3171/jns.2000.92.4.0626\u003c/li\u003e\n\u003cli\u003eGinsburg AS, Liddy Z, Khazaneh PT, et al. Barriers and facilitators to ultrasound use in low- and middle-income countries. Sci Rep. 2023;13:3322. doi:10.1038/s41598-023-30454-w\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"pediatric-surgery-international","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pesi","sideBox":"Learn more about [Pediatric Surgery International](http://link.springer.com/journal/383)","snPcode":"383","submissionUrl":"https://submission.nature.com/new-submission/383/3","title":"Pediatric Surgery International","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Colorectal, global surgery, anorectal malformation, ARM, survey, international","lastPublishedDoi":"10.21203/rs.3.rs-8764567/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8764567/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eAll patients born with anorectal malformations (ARMs) deserve high-quality healthcare, including appropriate neonatal screening, perioperative management, and long-term follow-up. This study examined global pediatric surgical practices for ARM management, identifying areas of consensus and variability in perioperative care and reported outcomes.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e A multi-center survey distributed by The Hendren Project (a global networked community of pediatric surgeons) invited surgeons to retrospectively review their ten most recent primary ARM reconstructions, excluding reoperations. Data were compared by country/continent and World Bank income.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 144 surgeons from 90 hospitals in 50 countries reported outcomes for 900 patients. Sacral radiographs were inconsistently obtained, with 34.2% lacking lateral views and 21.9% missing anterior-posterior views. The complication rate after PSARP was 27.2%, including dehiscence (11.7%), wound infection (7.4%), and stricture (6.9%). Divided stomas were more common than loop colostomies (66.3% versus 28.8%). Postoperative anal dilations were performed by 92.6% of surgeons. Reported complication rates did not differ significantly by region or income category.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis global survey demonstrates wide regional and income-based variability in ARM perioperative care, spanning screening, operative strategy, timing, and postoperative management. Inconsistent sacral and spinal screening, especially in low-resource settings, highlights needs for standardized pathways and context-aware quality improvement efforts worldwide.\u003c/p\u003e","manuscriptTitle":"Pediatric Surgical Care of Anorectal Malformations: A Global Survey","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-11 18:19:15","doi":"10.21203/rs.3.rs-8764567/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-25T10:53:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"63730108444962604667862666439336428656","date":"2026-04-23T10:04:42+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-03T15:46:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"42019736423532737081961645110569442011","date":"2026-03-24T16:17:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"226995262285881964057845643843289562196","date":"2026-02-14T18:16:26+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-09T09:58:04+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-03T21:43:55+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-03T14:13:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"Pediatric Surgery International","date":"2026-02-02T11:25:14+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"pediatric-surgery-international","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pesi","sideBox":"Learn more about [Pediatric Surgery International](http://link.springer.com/journal/383)","snPcode":"383","submissionUrl":"https://submission.nature.com/new-submission/383/3","title":"Pediatric Surgery International","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"b38eee16-62dd-456c-8245-71f2d061fa22","owner":[],"postedDate":"February 11th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-11T18:19:15+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-11 18:19:15","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8764567","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8764567","identity":"rs-8764567","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}