Classic Divided Sigmoidostomy Vs Loop Sigmoidostomy in Anorectal Malformations: Time for Change?

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Carla Ramirez-Amoros, Catarina Carvalho, María San Basilio, Leopoldo Martinez, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4730029/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 10 Sep, 2024 Read the published version in Pediatric Surgery International → Version 1 posted 9 You are reading this latest preprint version Abstract Purpose Divided sigmoidostomy (DS) is the classic stoma for patients with anorectal malformations (ARM). Loop sigmoidostomies (LS) in ARM are associated with higher risk of stoma prolapse and urinary tract infections (UTI). This is not clearly supported by literature. We compared our experience with both techniques. Methods Retrospective study of ARM patients who underwent DS or LS between 2013–2023. We analysed demographics, associated malformations, intraoperative variables, oral intake and stoma functioning times, hospital stay, complications, prolapses, and UTI. Results Of 40 patients, 29 underwent open DS and 11 laparoscopic LS. Demographics, malformation type, associated anomalies, surgical time, intraoperative and anaesthetic complications were comparable. Postoperative complications were higher in DS than LS [14(48.3%) vs 1(9.1%), (p = 0.02)], mostly due to wound complications [12(41.3%) vs 0(0%), (p = 0.01)]; with 3 dehiscenses and 3 strictures reintervened. The hours to oral intake and stoma functioning were higher for DS [48(39–90) and 48(24–48) vs 24(24–48) and 24(24–24), (p 0.05)] were comparable. Conclusion LS in ARM patients have no higher risk of prolapse or UTI than DS. DS had more complications, mostly wound infections, strictures and dehiscenses. Figures Figure 1 Figure 2 Introduction The treatment of anorectal malformations (ARM) is surgical reconstruction with the creation of a neo-anus. However, prior to this definitive repair, excluding lower and less severe malformations, a colostomy is performed in the first hours of life to divert faecal contents. Divided sigmoidostomy (DS) is the traditional and widely used approach( 1 ). This particular type of stoma is mainly indicated on patients with ARM and has no other indication in paediatric surgery. The two main reasons why this type of stoma is done on ARM patients are that it allows for the mucosal fistula to remain outside the stoma bag to avoid the spillage of faeces. This mucous fistula also allows access to the distal bowel to perform a high pressure distal colostogram to help identify the anatomy of the recto-urinary or recto-gynaecological fistula before definitive repair. For this last reason, a Hartmann or end colostomy would not be indicated. The classic open approach to perform a DS involves a larger left lower oblique incision and complete section of the bowel, leaving the proximal end of the colostomy and the mucous fistula at two separate points in the abdomen with a skin gap in between( 2 ). Loop colostomies in ARM have traditionally been associated with a higher risk of urinary tract infections (UTI), due to the passage of faecal contents into the distal loop; a higher risk of stoma prolapse, due to greater difficulty in fixing it to the fascia through a smaller incision; and a higher risk of loop rotation when pulling it through a smaller incision with less field of view( 3 ). However, the current literature seems to refute these beliefs, as there is no evidence of an increased risk of UTIs in patients with an ARM affecting the urinary system who have a LS versus a DS( 4 ). The increased risk of stoma prolapse is described in some publications( 5 ) but has not been found in others( 6 ). As for the risk of loop rotation, this is solved with the laparoscopic approach, which allows visualisation of the correct externalisation of the sigmoid( 7 ). In addition, while closing a DS requires a laparotomy, a LS involves a less complex operation and less intrusion into the abdominal cavity with its associated risk of adhesions( 8 ). We aimed to review our series of patients with ARM and compare the results obtained when performing a classic DS versus a laparoscopic LS. Materials and Methods We performed a retrospective study of ARM patients who underwent DS or LS between 2013–2023. Patients were stratified into two groups according to the type of sigmoidostomy performed. Patient eligibility Patients with recto-perineal fistulas were not generally eligible to perform a stoma, although it can exceptionally be done in cases with severe associated comorbidities or instability. A stoma was indicated in patients with recto-vestibular fistulas when dilations by the family were not feasible or when severe associated anomalies were identified. In patients with no fistula a sigmoidostomy was indicated only if the cross lateral x-ray showed a high distal rectal pouch (> 1cm from the perineal skin). Lastly, all patients with recto-urethral fistulas and cloacas had the indication to perform a stoma. Surgical Techniques DS were performed by the classic technique with a left lower quadrant oblique incision. After dividing the fascia and identifying the junction between the sigmoid and left colon, the bowel loop was divided whilst preserving the vascular arcade. The sigmoidostomy and the mucous fistula were both fixed at opposite ends of the incision and the fascia gap between them was closed (Fig. 1 A). A laparoscopic approach was used for LS, introducing the laparoscope through a 5 mm infraumbilical port and the bowel grasper through a 3 mm port on the left lower quadrant, through which the bowel loop was exteriorised. The incision on the bowel was made transversally to create a turnbull stoma, with the proximal segment matured higher and the distal one flat (Fig. 1 B). In both types of stomas, the stoma bag was placed at the end of the operation and a specialized stoma nurse took care of its management and parent training. Perioperative management: Both groups were preoperatively studied to rule out VACTERL association. They all received the same preoperative and postoperative antibiotic prophylaxis with amoxicillin clavulanic acid, which was maintained for 5 days postoperatively. Data analysed We analysed sex, gestational age and age at which the operation was performed, type of ARM and associated malformations, surgical time, anaesthetic or surgical complications, time to oral intake and stoma functioning, postoperative complications and length of hospital stay. After the initial discharge, we also analysed stoma prolapses, UTI (considered as such when a positive culture was obtained, accompanied by urinary symptoms, fever or a compatible blood test), problems when performing the augmented-pressure distal colostogram and complications after stoma closure. We excluded patients whose colostomy had been done in another centre or with a different surgical technique. Statistical analysis Clinical data was entered into a database (Microsoft Excel 2019; Microsoft Corporation, Redmond, WA, USA), and statistical analysis was performed using SPSS for MAC OSX (version 25; IBM Corp., Armonk, NY, USA). Qualitative variables are reflected as absolute numbers or percentages, while quantitative variables are shown as medians and 25th and 75th percentiles given that none followed a normal distribution when tested with the Kolmogórov-Smirnov test. The x 2 and Mann Whitney tests were used for the comparative analysis of the variables, considering the values with p < 0.05 as significant. Results Patient characteristics We reviewed 40 patients, of which 11 (27.5%) underwent a laparoscopic LS and 29 (72.5%) an open DS. Both groups were comparable in terms of demographics, with 54.4% vs. 51.7% females; a birth weight of 2985 (2153–3354) vs. 2520 (1890–3147) grams and a gestational age of 39 + 4 (37 + 6–41 + 2) vs. 37 + 6 (34 + 1–39 + 4) weeks for the LS and DS groups respectively. Of the patients who underwent a LS, 6 (54.5%) had a rectovestibular fistula, 2 (18%) a rectourethral fistula (1 rectoprostatic and 1 rectobulbar), 1 (9%) a rectoperineal fistula, 1 (9%) a rectovesical fistula and 1 (9%) an imperforated anus with no fistula. On the other hand, in the DS group there were 8 (27.5%) rectourethral fistulas (6 rectobulbar and 2 rectoprostatic), 6 (20.7%) rectovestibular fistulas, 6 (20.7%) imperforated anus with no fistula, 4 (13.7%) cloacas, 2 (7%) rectoperineal fistulas, 2 (7%) H-type fistulas and 1 (3.4%) rectovaginal fistula. Both groups had a comparable incidence of associated malformations, 8 (72.7%) patients in the LS group and 25 (86.2%) in DS. Of these, 2 (18%) LS patients and 11 (37%) DS presented associated urological malformations, whilst 5 (45.5%) and 11 (37.9%) respectively meet criteria for VACTERL association. Table 1 . Table 1 Associated malformations Associated malformations in LS patients Urological malformations VACTERL Labium majus vulvae lipoma, PDA, PFO,filum terminale lipoma No Yes Bicuspid aortic valve, double SVC system, low conus medullaris with syringomyelia, caudal regression syndrome No Yes Vertebral fusion No No ASD, filum terminale lipoma, sacral vertebrae anomalies No Yes VSD, coccygeal agenesis No Yes Currarino syndrome No No Bladder duplication, urogenital sinus, left renal agenesis Yes Yes VSD, right renal dysplasia, left duplex kidney, cryptorchidism, cleft lip Yes Yes Associated malformations in DS patients Urological malformations VACTERL Ventricular septal defect (VSD), vertebral fusion, hydrocephalus No Yes Oesophageal atresia, hemivertebrae, VSD, laryngeal cleft No Yes Rubindtein-Taybi Syndrome, posterior urethral valves (PUV) Yes No Vaginal atresia, hemivertebrae No No Oesophageal atresia, right renal agenesis Yes Yes Atrial septal defect (ASD), long bone deformities No Yes Down síndrome No No Down síndrome No No Cudal regression síndrome No No Down syndrome, ASD No No Right renal agenesis, left ureterohydronephrosis, uterus didelphys with vaginal duplication, congenital hypothyroidism Yes No Oesophageal atresia, lung atresia, vertebral fusion, skeletal limb anomalies with bilateral radial deviation, syringomelia No Yes Persistent foramen ovale (PFO) No No Multicystic dysplastic kidney Yes No ASD, bilateral radius agenesis and right tibia agenesis, tracheal stenosis No Yes Hydrometrocolpos with double uterus and vagina and distal atresia of the right hemivagina, severe bilateral hydronephrosis Yes No PFO, ASD, VSD, multicystic kidney Yes Yes Prune belly syndrome (megabladder, bilateral renal dysplasia), pulmonary hypoplasia and hypertension, clubfeet, ambiguous genitalia, lumbosacral fistula Yes No PFO, patent ductus arteriosus (PDA) No No Sacral agenesis, hemivertebrae, tethered cord, Townes-Brocks syndrome, neuropathic bladder No Yes Oesophageal atresia, vertebral anomalies, VSD, tethered cord No Yes Congenital laryngeal membrane, unilateral renal agenesis, coccygeal agenesis, oesophageal stenosis Yes Yes Persistent left superior vena cava, PFO No No Tetralogy of Fallot, left renal agenesis, ureteropelvic junction obstruction, congenital hyperinsulinism Yes Yes Caudal regression syndrome, myelomeningocele, complex genital malformation (no corpora cavernosa), PFO, ectopic left kidney, Arnold Chiari II malformation Yes No The patients underwent LS formation with a median age of 1.6 (1-120) days and DS at 1 ( 1 – 2 ) days, (p = 0.2). There were no differences in surgical time, 70 (65–105) vs. 80 (56–95) minutes, or anaesthetic complications. Of the 40 patients studied only one, who underwent a laparoscopic LS, suffered an anaesthetic complication consisting on difficulty in ventilation and bronchospasm which subsided after the administration of hydrocortisone and salbutamol. As for the postoperative variables, the hours to oral intake and stoma functioning were higher for DS: 48 (39–90) and 48 (24–48) hours vs. 24 (24–48) and 24 (24–24) hours for LS, (p < 0.05). The days of hospital stay after the operation were also significantly higher when a DS was performed, 36 (19–60) vs. 8 ( 5 – 10 ), (p = 0.001). There were more patients with postoperative surgical complications in DS compared to LS, 14 (48.3%) vs 1 (9.1%), (p = 0.02). The complication in the laparoscopic LS group was a stricture that required reintervention. As for open DS, several patients had multiple complications, reaching a total of 18 complications. There were 10 (34.4%) wound dehiscences, 2 (6.8%) wound infections, 4 (13.7%) stoma strictures and 1 (3.4%) granuloma bleeding. Of these, 3 dehiscences and 3 strictures (one with a proximal intestinal perforation) were reintervened (Fig. 2 ). Overall, the complications were mostly at the expense of wound complications, which occurred in 12 (41.3%) patients with DS vs. 0 (0%) with LS, (p = 0.01). Table 2 . Table 2 Surgical complications Complications in LS patients Treatment Late stricture with development of intestinal obstruction. Surgical revision with resection of stricture and new sigmoidistomy formation. Complications in DS patients Treatment Wound dehiscence. Conservative, closure by second intention. Wound dehiscence. Conservative, closure by second intention. Wound dehiscence. Conservative, closure by second intention. Wound dehiscence. Surgical revision of wound on post-operative day 8. Wound dehiscence. Conservative, closure by second intention. Wound dehiscence. Conservative, closure by second intention. Wound dehiscence. Conservative, closure by second intention. Wound dehiscence and later stricture. Surgical revision of wound on post-operative day 16 and surgical treatment of stricture 3 months postoperatively. Wound dehiscence and later stricture. Conservative treatment of dehiscence and surgical treatment of stricture 1 month postoperatively. Wound dehiscence and later stricture. Conservative treatment of dehiscence and surgical treatment of stricture at the time of the PSARP. Wound infection. Conservative treatment with local antibiotic course. Wound infection. Conservative treatment with wound cleansing. Wound stricture with later proximal intestinal perforation. Surgical treatment of perforation with ileostomy formation 4 months postoperatively. Wound granuloma bleeding. Conservative, cautery with silver nitrate stick. There were no statistically significant differences in prolapses, which occurred in one patient in each group (3.4% DS vs 9.1% LS), or UTIs, which were 3 (10.3%) in DS and 1 (9.1%) in LS. All the patients with UTIs presented a recto-urinary fistula and additional urological malformations: PUV, a multicystic dysplastic kidney and prune belly syndrome (megabladder with bilateral renal dysplasia) in the 3 DS patients and right renal dysplasia with left duplex kidney in the LS patient. They were all treated with a course of out-patient antibiotics. No patients from either group had problems when performing the augmented-pressure distal colostogram and none of the LS required the distal end of the stoma to be closed to prevent passage of faecal contents. In all cases, the stoma was closed after the creation of the neo-anus with a posterior sagittal anorectoplasty. This was done 9.23 (6.80–10.70) months after its creation in LS and 15.93 (10.66–19.23) months in DS, the latter with a statistically significant delay (p = 0.005) and a non-significant higher rate of wound complications, 6 (22.2%) vs 0 (0%). Discussion The ideal colostomy for patients with ARM has long been a subject of debate for paediatric surgeons ( 3 , 9 ). A divided colostomy at the junction of the descending and sigmoid colon as recommended by Peña has been widely been considered the standard approach ( 10 , 11 ). Amongst its advantages Peña describes the avoidance of spillage from proximal to distal bowel, which in turn avoids impacted distal stool and urinary tract infections; the easy performance of distal colostograms and its low incidence of prolapse. However, this technique is also not without complications, including excoriation, dehiscence, bleeding, stenosis/ obstruction, parastomal herniae and intra-abdominal adhesions ( 8 , 12 ). In our series, DS formation had a significantly higher rate of complications, especially those related to the surgical wound. The higher risk of UTI was one of the main arguments against LS. However, in line with the current literature, our findings point to there not being a difference between techniques. Youssefet al. conducted a metanalysis comparing DS and LS, with approximately 500 patients in each arm, which was unable to find differences in UTI between both groups ( 2 ). It may actually be an intrinsic risk of ARM, especially in patients with a recto-urinary fistula, concomitant vesicoureteral reflux ( 13 ) or other genitourinary malformations ( 14 ), independent of the type of colostomy ( 3 , 8 ). Also in relation to the believed risk of passage of stool to the distal loop, there are studies that shown no increased risk of megarectum ( 5 , 14 ). Perhaps this risk can be reduced by performing a thorough distal bowel washout during the initial stoma formation ( 8 ). In our series, no patients required the distal end of the stoma to be closed to prevent faecal impactation and there were no problems when performing the augmented-pressure distal colostogram. As for the increased risk of stoma prolapse, although our series did not find a significant difference between the groups, the literature is divided. The metanalysis conducted by Youssefet al. favoured divided over loop colostomies for the incidence of stoma prolapse. However, the two groups had a significant heterogeneity and the majority of the loop colostomies on the reports that showed a higher risk of prolapse were mainly at the transverse colon ( 1 , 5 ). It seems that the risk of prolapse is mainly associated to the portion of the colon used for the colostomy, with a higher risk when a mobile portion is used ( 1 ). The studies that opt for a LS, taking advantage of the retroperitoneal attachment immediately distal to the descending colon have a prolapse rate comparable to DS ( 3 , 8 , 14 ). Another factor that has been reported to contribute to prolapse is the delayed closure of the stoma ( 9 ), which in our case was done earlier than for DS and within the first 10 months. The laparoscopic approach also has a number of advantages, in addition to the evidently better cosmetic result of a laparotomy versus two or even a single( 7 ) small port incision. The restricted field of view that was initially considered a disadvantage of the small incision of LS has been turned into the possibility to explore the entire abdomen with the laparoscopic approach. Thanks to this, the pelvic structures and possible mullerian malformations can be explored, and the risk of loop rotation reduced given the visualisation of the correct externalisation of the sigma ( 7 ). On the other hand, laparoscopy entails a lower risk of adhesion formations and therefore fewer adhesion-related complications like intestinal obstruction requiring surgical treatment ( 15 ), whose incidence following neonatal laparotomy has been described as 6–8% ( 16 ). The lower degree of tissue manipulation could also contribute to a reduced impairment of gut motility, which we can clearly see reflected in the earlier stoma functioning and oral intake in LS versus DS in our series. This, in addition to the improved pain management of the smaller wounds, contributed to an earlier discharge for LS patients. Some authors have described the laparoscopic approach for DS, using a first port on the site of the future stoma to externalise and divide the sigmoid colon extracorporeally and a second port to afterwards exteriorise the distal mucous fistula ( 17 ). In addition to all the previously described advantages of the laparoscopic approach for LS, this technique for DS also eliminates the incision between the two stomas and its complications. These authors describe that when taking down this DS, two transverse incisions can be done with good cosmetic results. However, in some cases an incision between the two ends is still required to be able to close the stoma securely. Taking the DS down, especially when done open but also in some laparoscopic cases, is a more complex operation that requires a laparotomy, with the disadvantages previously described. Also, although our results do not reach statistical significance, likely due to insufficient sample size, the higher tendency to wound complications after DS closure merits consideration and further study. The limitations of this study include its retrospective and observational nature with a limited number of patients. However, given the current literature and shift towards loop colostomies in some institutions, with reduced literature in the matter, we considered our results of interest. Conclusion Laparoscopic LS in ARM patients is an easier procedure to perform and close, with a reduced surgical wound and the possibility to explore the pelvis. It does not have a higher risk of prolapse or UTI compared to the classic DS. Furthermore, DS had more postoperative complications, longer time to oral intake and stoma functioning and a more prolonged hospital stay. Declarations Funding : The authors did not receive support from any organization for the submitted work. Competing interests : The authors have no competing interests to declare that are relevant to the content of this article. Ethics approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by the Bioethics Committee of La Paz University Hospital (No. 2024.005). Consent to participate and or publish : Written informed consent was obtained from the parents or legal guardians. Data availability: The data that support the findings of this study are available from the corresponding author, upon reasonable request. References Pena A, Migotto-Krieger M, Levitt MA. Colostomy in anorectal malformations: A procedure with serious but preventable complications. J Pediatr Surg. 2006 Apr;41(4):748–56. Youssef F, Arbash G, Puligandla PS, Baird RJ. Loop versus divided colostomy for the management of anorectal malformations: a systematic review and meta-analysis. J Pediatr Surg. 2017 May;52(5):783–90. Van Den Hondel D, Sloots C, Meeussen C, Wijnen R. To split or not to split: Colostomy complications for anorectal malformations or hirschsprung disease: A single center experience and a systematic review of the literature. European Journal of Pediatric Surgery. 2014 Feb;24(1):61–9. Kim W, Lee S, Seo JM. Vesicoureteral reflux increases the risk of urinary tract infection prior to corrective surgery in newborn males with anorectal malformation. Pediatr Surg Int. 2020 Dec 1;36(12):1495–500. Oda O, Davies D, Colapinto K, Gerstle JT. Loop versus divided colostomy for the management of anorectal malformations. J Pediatr Surg. 2014 Jan;49(1):87–90. Liechty ST, Barnhart DC, Huber JT, Zobell S, Rollins MD. The morbidity of a divided stoma compared to a loop colostomy in patients with anorectal malformation. J Pediatr Surg. 2016 Jan;51(1):107–10. Liem NT, Quynh TA. Single trocar laparoscopic-assisted colostomy in newborns. Pediatr Surg Int. 2013 Jun;29(6):651–3. Mullassery D, Iacona R, Cross K, Blackburn S, Kiely E, Eaton S, et al. Loop colostomies are safe in anorectal malformations. J Pediatr Surg. 2018 Nov;53(11):2170–3. Gardikis S, Antypas S, Mamoulakis C, Demetriades D, Dolatzas T, Tsalkidis A, et al. Colostomy type in anorectal malformations: 10-years experience. Minerva Pediatr. 2004 Aug;56(4):425–9. Levitt MA, Peña A. Anorectal malformations. Vol. 2, Orphanet Journal of Rare Diseases. BioMed Central Ltd.; 2007. Peña A, Devries PA. Posterior sagittal anorectoplasty: Important technical considerations and new applications. J Pediatr Surg. 1982 Dec;17(6):796–811. Çiğdem MK, Onen A, Duran H, Öztürk H, Otçu S. The mechanical complications of colostomy in infants and children: analysis of 473 cases of a single center. Pediatr Surg Int. 2006 Aug 13;22(8):671–6. Sanchez S, Ricca R, Joyner B, Waldhausen JHT. Vesicoureteral reflux and febrile urinary tract infections in anorectal malformations: A retrospective review. J Pediatr Surg. 2014 Jan;49(1):91–4. Liechty ST, Barnhart DC, Huber JT, Zobell S, Rollins MD. The morbidity of a divided stoma compared to a loop colostomy in patients with anorectal malformation. J Pediatr Surg. 2016 Jan;51(1):107–10. Anderson SA, Beierle EA, Chen MK. Role of laparoscopy in the prevention and in the treatment of adhesions. Semin Pediatr Surg. 2014 Dec 1;23(6):353–6. Choudhry MS, Grant HW. Small bowel obstruction due to adhesions following neonatal laparotomy. Pediatr Surg Int. 2006 Sep 14;22(9):729–32. Gine C, Santiago S, Lara A, Laín A, Lane V, Wood R, et al. Two-Port Laparoscopic Descending Colostomy with Separated Stomas for Anorectal Malformations in Newborns. European Journal of Pediatric Surgery. 2015 Nov 3;26(05):462–4. Additional Declarations No competing interests reported. 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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-4730029","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":329821870,"identity":"fecf2cad-f574-4547-bee5-b900d34d901d","order_by":0,"name":"Carla Ramirez-Amoros","email":"data:image/png;base64,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","orcid":"","institution":"La Paz Children’s University Hospital","correspondingAuthor":true,"prefix":"","firstName":"Carla","middleName":"","lastName":"Ramirez-Amoros","suffix":""},{"id":329821871,"identity":"2ee5cad6-7d78-40ca-9ebe-b567a20b82c1","order_by":1,"name":"Catarina Carvalho","email":"","orcid":"","institution":"Centro Materni Infantil Do Norte","correspondingAuthor":false,"prefix":"","firstName":"Catarina","middleName":"","lastName":"Carvalho","suffix":""},{"id":329821872,"identity":"69bde3c4-bdc1-452a-8d65-5caa97a2898d","order_by":2,"name":"María San Basilio","email":"","orcid":"","institution":"La Paz Children’s University Hospital","correspondingAuthor":false,"prefix":"","firstName":"María","middleName":"San","lastName":"Basilio","suffix":""},{"id":329821873,"identity":"adbca1f1-ff50-49d7-b581-c2f4c60085b1","order_by":3,"name":"Leopoldo Martinez","email":"","orcid":"","institution":"La Paz Children’s University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Leopoldo","middleName":"","lastName":"Martinez","suffix":""},{"id":329821874,"identity":"1317b7ca-d91d-46ab-9fb7-cd396baa0bd6","order_by":4,"name":"Jose Luis Encinas","email":"","orcid":"","institution":"La Paz Children’s University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jose","middleName":"Luis","lastName":"Encinas","suffix":""},{"id":329821875,"identity":"75aa78ba-4bc2-4450-b04d-6d4d353b8cda","order_by":5,"name":"Alejandra Vilanova-Sanchez","email":"","orcid":"","institution":"La Paz Children’s University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Alejandra","middleName":"","lastName":"Vilanova-Sanchez","suffix":""}],"badges":[],"createdAt":"2024-07-12 11:46:39","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4730029/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4730029/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00383-024-05834-6","type":"published","date":"2024-09-10T15:57:43+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":62220529,"identity":"61d2cdd4-0323-4b56-bc89-bd25e45857a9","added_by":"auto","created_at":"2024-08-11 12:22:45","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":139748,"visible":true,"origin":"","legend":"\u003cp\u003eImmediate postoperative results. A: Divided sigmoidostomy. B: Loop sigmoidostomy\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4730029/v1/5ebd5618b565dbb7496c343c.png"},{"id":62219513,"identity":"2902a8f6-cdc9-4855-8109-a3001aac8d82","added_by":"auto","created_at":"2024-08-11 12:14:45","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":239984,"visible":true,"origin":"","legend":"\u003cp\u003ePostoperative complications. A, B, C: Wound dehiscences that were reintervened D: Stricture after the dehiscence shown in C, also reintervened\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-4730029/v1/d99028438c195d793a85b225.png"},{"id":64619125,"identity":"66b45bd2-78b2-4228-9330-d8ef4c9d9bc3","added_by":"auto","created_at":"2024-09-16 16:11:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1078519,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4730029/v1/c370071a-df83-43ac-a0b6-3e08b4576de8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eClassic Divided Sigmoidostomy Vs Loop Sigmoidostomy in Anorectal Malformations: Time for Change?\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe treatment of anorectal malformations (ARM) is surgical reconstruction with the creation of a neo-anus. However, prior to this definitive repair, excluding lower and less severe malformations, a colostomy is performed in the first hours of life to divert faecal contents. Divided sigmoidostomy (DS) is the traditional and widely used approach(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). This particular type of stoma is mainly indicated on patients with ARM and has no other indication in paediatric surgery. The two main reasons why this type of stoma is done on ARM patients are that it allows for the mucosal fistula to remain outside the stoma bag to avoid the spillage of faeces. This mucous fistula also allows access to the distal bowel to perform a high pressure distal colostogram to help identify the anatomy of the recto-urinary or recto-gynaecological fistula before definitive repair. For this last reason, a Hartmann or end colostomy would not be indicated. The classic open approach to perform a DS involves a larger left lower oblique incision and complete section of the bowel, leaving the proximal end of the colostomy and the mucous fistula at two separate points in the abdomen with a skin gap in between(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eLoop colostomies in ARM have traditionally been associated with a higher risk of urinary tract infections (UTI), due to the passage of faecal contents into the distal loop; a higher risk of stoma prolapse, due to greater difficulty in fixing it to the fascia through a smaller incision; and a higher risk of loop rotation when pulling it through a smaller incision with less field of view(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). However, the current literature seems to refute these beliefs, as there is no evidence of an increased risk of UTIs in patients with an ARM affecting the urinary system who have a LS versus a DS(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). The increased risk of stoma prolapse is described in some publications(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) but has not been found in others(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). As for the risk of loop rotation, this is solved with the laparoscopic approach, which allows visualisation of the correct externalisation of the sigmoid(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). In addition, while closing a DS requires a laparotomy, a LS involves a less complex operation and less intrusion into the abdominal cavity with its associated risk of adhesions(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). We aimed to review our series of patients with ARM and compare the results obtained when performing a classic DS versus a laparoscopic LS.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eWe performed a retrospective study of ARM patients who underwent DS or LS between 2013\u0026ndash;2023. Patients were stratified into two groups according to the type of sigmoidostomy performed.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatient eligibility\u003c/h2\u003e \u003cp\u003ePatients with recto-perineal fistulas were not generally eligible to perform a stoma, although it can exceptionally be done in cases with severe associated comorbidities or instability. A stoma was indicated in patients with recto-vestibular fistulas when dilations by the family were not feasible or when severe associated anomalies were identified. In patients with no fistula a sigmoidostomy was indicated only if the cross lateral x-ray showed a high distal rectal pouch (\u0026gt;\u0026thinsp;1cm from the perineal skin). Lastly, all patients with recto-urethral fistulas and cloacas had the indication to perform a stoma.\u003c/p\u003e \u003cp\u003e \u003cem\u003eSurgical Techniques\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDS were performed by the classic technique with a left lower quadrant oblique incision. After dividing the fascia and identifying the junction between the sigmoid and left colon, the bowel loop was divided whilst preserving the vascular arcade. The sigmoidostomy and the mucous fistula were both fixed at opposite ends of the incision and the fascia gap between them was closed (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA).\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eA laparoscopic approach was used for LS, introducing the laparoscope through a 5 mm infraumbilical port and the bowel grasper through a 3 mm port on the left lower quadrant, through which the bowel loop was exteriorised. The incision on the bowel was made transversally to create a turnbull stoma, with the proximal segment matured higher and the distal one flat (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB).\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eIn both types of stomas, the stoma bag was placed at the end of the operation and a specialized stoma nurse took care of its management and parent training.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePerioperative management:\u003c/p\u003e \u003cp\u003eBoth groups were preoperatively studied to rule out VACTERL association. They all received the same preoperative and postoperative antibiotic prophylaxis with amoxicillin clavulanic acid, which was maintained for 5 days postoperatively.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData analysed\u003c/h2\u003e \u003cp\u003eWe analysed sex, gestational age and age at which the operation was performed, type of ARM and associated malformations, surgical time, anaesthetic or surgical complications, time to oral intake and stoma functioning, postoperative complications and length of hospital stay. After the initial discharge, we also analysed stoma prolapses, UTI (considered as such when a positive culture was obtained, accompanied by urinary symptoms, fever or a compatible blood test), problems when performing the augmented-pressure distal colostogram and complications after stoma closure. We excluded patients whose colostomy had been done in another centre or with a different surgical technique.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eClinical data was entered into a database (Microsoft Excel 2019; Microsoft Corporation, Redmond, WA, USA), and statistical analysis was performed using SPSS for MAC OSX (version 25; IBM Corp., Armonk, NY, USA). Qualitative variables are reflected as absolute numbers or percentages, while quantitative variables are shown as medians and 25th and 75th percentiles given that none followed a normal distribution when tested with the Kolmog\u0026oacute;rov-Smirnov test. The x\u003csup\u003e2\u003c/sup\u003e and Mann Whitney tests were used for the comparative analysis of the variables, considering the values with p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 as significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003ePatient characteristics\u003c/h2\u003e \u003cp\u003eWe reviewed 40 patients, of which 11 (27.5%) underwent a laparoscopic LS and 29 (72.5%) an open DS. Both groups were comparable in terms of demographics, with 54.4% vs. 51.7% females; a birth weight of 2985 (2153\u0026ndash;3354) vs. 2520 (1890\u0026ndash;3147) grams and a gestational age of 39\u0026thinsp;+\u0026thinsp;4 (37\u0026thinsp;+\u0026thinsp;6\u0026ndash;41\u0026thinsp;+\u0026thinsp;2) vs. 37\u0026thinsp;+\u0026thinsp;6 (34\u0026thinsp;+\u0026thinsp;1\u0026ndash;39\u0026thinsp;+\u0026thinsp;4) weeks for the LS and DS groups respectively. Of the patients who underwent a LS, 6 (54.5%) had a rectovestibular fistula, 2 (18%) a rectourethral fistula (1 rectoprostatic and 1 rectobulbar), 1 (9%) a rectoperineal fistula, 1 (9%) a rectovesical fistula and 1 (9%) an imperforated anus with no fistula. On the other hand, in the DS group there were 8 (27.5%) rectourethral fistulas (6 rectobulbar and 2 rectoprostatic), 6 (20.7%) rectovestibular fistulas, 6 (20.7%) imperforated anus with no fistula, 4 (13.7%) cloacas, 2 (7%) rectoperineal fistulas, 2 (7%) H-type fistulas and 1 (3.4%) rectovaginal fistula. Both groups had a comparable incidence of associated malformations, 8 (72.7%) patients in the LS group and 25 (86.2%) in DS. Of these, 2 (18%) LS patients and 11 (37%) DS presented associated urological malformations, whilst 5 (45.5%) and 11 (37.9%) respectively meet criteria for VACTERL association. 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\u003eAssociated malformations\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAssociated malformations in LS patients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUrological malformations\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVACTERL\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLabium majus vulvae lipoma, PDA, PFO,filum terminale lipoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBicuspid aortic valve, double SVC system, low conus medullaris with syringomyelia, caudal regression syndrome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVertebral fusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASD, filum terminale lipoma, sacral vertebrae anomalies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVSD, coccygeal agenesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurrarino syndrome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBladder duplication, urogenital sinus, left renal agenesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVSD, right renal dysplasia, left duplex kidney, cryptorchidism, cleft lip\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAssociated malformations in DS patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUrological malformations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVACTERL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVentricular septal defect (VSD), vertebral fusion, hydrocephalus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOesophageal atresia, hemivertebrae, VSD, laryngeal cleft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRubindtein-Taybi Syndrome, posterior urethral valves (PUV)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVaginal atresia, hemivertebrae\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOesophageal atresia, right renal agenesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAtrial septal defect (ASD), long bone deformities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDown s\u0026iacute;ndrome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDown s\u0026iacute;ndrome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCudal regression s\u0026iacute;ndrome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDown syndrome, ASD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight renal agenesis, left ureterohydronephrosis, uterus didelphys with vaginal duplication, congenital hypothyroidism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOesophageal atresia, lung atresia, vertebral fusion, skeletal limb anomalies with bilateral radial deviation, syringomelia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePersistent foramen ovale (PFO)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMulticystic dysplastic kidney\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASD, bilateral radius agenesis and right tibia agenesis, tracheal stenosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHydrometrocolpos with double uterus and vagina and distal atresia of the right hemivagina, severe bilateral hydronephrosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePFO, ASD, VSD, multicystic kidney\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrune belly syndrome (megabladder, bilateral renal dysplasia), pulmonary hypoplasia and hypertension, clubfeet, ambiguous genitalia, lumbosacral fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePFO, patent ductus arteriosus (PDA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSacral agenesis, hemivertebrae, tethered cord, Townes-Brocks syndrome, neuropathic bladder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOesophageal atresia, vertebral anomalies, VSD, tethered cord\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCongenital laryngeal membrane, unilateral renal agenesis, coccygeal agenesis, oesophageal stenosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePersistent left superior vena cava, PFO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTetralogy of Fallot, left renal agenesis, ureteropelvic junction obstruction, congenital hyperinsulinism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCaudal regression syndrome, myelomeningocele, complex genital malformation (no corpora cavernosa), PFO, ectopic left kidney, Arnold Chiari II malformation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\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\u003eThe patients underwent LS formation with a median age of 1.6 (1-120) days and DS at 1 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) days, (p\u0026thinsp;=\u0026thinsp;0.2). There were no differences in surgical time, 70 (65\u0026ndash;105) vs. 80 (56\u0026ndash;95) minutes, or anaesthetic complications. Of the 40 patients studied only one, who underwent a laparoscopic LS, suffered an anaesthetic complication consisting on difficulty in ventilation and bronchospasm which subsided after the administration of hydrocortisone and salbutamol.\u003c/p\u003e \u003cp\u003eAs for the postoperative variables, the hours to oral intake and stoma functioning were higher for DS: 48 (39\u0026ndash;90) and 48 (24\u0026ndash;48) hours vs. 24 (24\u0026ndash;48) and 24 (24\u0026ndash;24) hours for LS, (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The days of hospital stay after the operation were also significantly higher when a DS was performed, 36 (19\u0026ndash;60) vs. 8 (\u003cspan additionalcitationids=\"CR6 CR7 CR8 CR9\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), (p\u0026thinsp;=\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eThere were more patients with postoperative surgical complications in DS compared to LS, 14 (48.3%) vs 1 (9.1%), (p\u0026thinsp;=\u0026thinsp;0.02). The complication in the laparoscopic LS group was a stricture that required reintervention. As for open DS, several patients had multiple complications, reaching a total of 18 complications. There were 10 (34.4%) wound dehiscences, 2 (6.8%) wound infections, 4 (13.7%) stoma strictures and 1 (3.4%) granuloma bleeding. Of these, 3 dehiscences and 3 strictures (one with a proximal intestinal perforation) were reintervened (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Overall, the complications were mostly at the expense of wound complications, which occurred in 12 (41.3%) patients with DS vs. 0 (0%) with LS, (p\u0026thinsp;=\u0026thinsp;0.01). Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \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\u003eSurgical complications\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 \u003cp\u003eComplications in LS patients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTreatment\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLate stricture with development of intestinal obstruction.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSurgical revision with resection of stricture and new sigmoidistomy formation.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplications in DS patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTreatment\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound dehiscence.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConservative, closure by second intention.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound dehiscence.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConservative, closure by second intention.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound dehiscence.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConservative, closure by second intention.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound dehiscence.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSurgical revision of wound on post-operative day 8.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound dehiscence.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConservative, closure by second intention.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound dehiscence.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConservative, closure by second intention.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound dehiscence.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConservative, closure by second intention.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound dehiscence and later stricture.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSurgical revision of wound on post-operative day 16 and surgical treatment of stricture 3 months postoperatively.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound dehiscence and later stricture.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConservative treatment of dehiscence and surgical treatment of stricture 1 month postoperatively.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound dehiscence and later stricture.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConservative treatment of dehiscence and surgical treatment of stricture at the time of the PSARP.\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\u003eConservative treatment with local antibiotic course.\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\u003eConservative treatment with wound cleansing.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound stricture with later proximal intestinal perforation.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSurgical treatment of perforation with ileostomy formation 4 months postoperatively.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound granuloma bleeding.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConservative, cautery with silver nitrate stick.\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\u003eThere were no statistically significant differences in prolapses, which occurred in one patient in each group (3.4% DS vs 9.1% LS), or UTIs, which were 3 (10.3%) in DS and 1 (9.1%) in LS. All the patients with UTIs presented a recto-urinary fistula and additional urological malformations: PUV, a multicystic dysplastic kidney and prune belly syndrome (megabladder with bilateral renal dysplasia) in the 3 DS patients and right renal dysplasia with left duplex kidney in the LS patient. They were all treated with a course of out-patient antibiotics.\u003c/p\u003e \u003cp\u003eNo patients from either group had problems when performing the augmented-pressure distal colostogram and none of the LS required the distal end of the stoma to be closed to prevent passage of faecal contents.\u003c/p\u003e \u003cp\u003eIn all cases, the stoma was closed after the creation of the neo-anus with a posterior sagittal anorectoplasty. This was done 9.23 (6.80\u0026ndash;10.70) months after its creation in LS and 15.93 (10.66\u0026ndash;19.23) months in DS, the latter with a statistically significant delay (p\u0026thinsp;=\u0026thinsp;0.005) and a non-significant higher rate of wound complications, 6 (22.2%) vs 0 (0%).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe ideal colostomy for patients with ARM has long been a subject of debate for paediatric surgeons (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). A divided colostomy at the junction of the descending and sigmoid colon as recommended by Pe\u0026ntilde;a has been widely been considered the standard approach (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Amongst its advantages Pe\u0026ntilde;a describes the avoidance of spillage from proximal to distal bowel, which in turn avoids impacted distal stool and urinary tract infections; the easy performance of distal colostograms and its low incidence of prolapse. However, this technique is also not without complications, including excoriation, dehiscence, bleeding, stenosis/ obstruction, parastomal herniae and intra-abdominal adhesions (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). In our series, DS formation had a significantly higher rate of complications, especially those related to the surgical wound.\u003c/p\u003e \u003cp\u003eThe higher risk of UTI was one of the main arguments against LS. However, in line with the current literature, our findings point to there not being a difference between techniques. Youssefet al. conducted a metanalysis comparing DS and LS, with approximately 500 patients in each arm, which was unable to find differences in UTI between both groups (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). It may actually be an intrinsic risk of ARM, especially in patients with a recto-urinary fistula, concomitant vesicoureteral reflux (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) or other genitourinary malformations (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), independent of the type of colostomy (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Also in relation to the believed risk of passage of stool to the distal loop, there are studies that shown no increased risk of megarectum (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Perhaps this risk can be reduced by performing a thorough distal bowel washout during the initial stoma formation (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). In our series, no patients required the distal end of the stoma to be closed to prevent faecal impactation and there were no problems when performing the augmented-pressure distal colostogram.\u003c/p\u003e \u003cp\u003eAs for the increased risk of stoma prolapse, although our series did not find a significant difference between the groups, the literature is divided. The metanalysis conducted by Youssefet al. favoured divided over loop colostomies for the incidence of stoma prolapse. However, the two groups had a significant heterogeneity and the majority of the loop colostomies on the reports that showed a higher risk of prolapse were mainly at the transverse colon (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). It seems that the risk of prolapse is mainly associated to the portion of the colon used for the colostomy, with a higher risk when a mobile portion is used (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The studies that opt for a LS, taking advantage of the retroperitoneal attachment immediately distal to the descending colon have a prolapse rate comparable to DS (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Another factor that has been reported to contribute to prolapse is the delayed closure of the stoma (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), which in our case was done earlier than for DS and within the first 10 months.\u003c/p\u003e \u003cp\u003eThe laparoscopic approach also has a number of advantages, in addition to the evidently better cosmetic result of a laparotomy versus two or even a single(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) small port incision. The restricted field of view that was initially considered a disadvantage of the small incision of LS has been turned into the possibility to explore the entire abdomen with the laparoscopic approach. Thanks to this, the pelvic structures and possible mullerian malformations can be explored, and the risk of loop rotation reduced given the visualisation of the correct externalisation of the sigma (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). On the other hand, laparoscopy entails a lower risk of adhesion formations and therefore fewer adhesion-related complications like intestinal obstruction requiring surgical treatment (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), whose incidence following neonatal laparotomy has been described as 6\u0026ndash;8% (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). The lower degree of tissue manipulation could also contribute to a reduced impairment of gut motility, which we can clearly see reflected in the earlier stoma functioning and oral intake in LS versus DS in our series. This, in addition to the improved pain management of the smaller wounds, contributed to an earlier discharge for LS patients. Some authors have described the laparoscopic approach for DS, using a first port on the site of the future stoma to externalise and divide the sigmoid colon extracorporeally and a second port to afterwards exteriorise the distal mucous fistula (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). In addition to all the previously described advantages of the laparoscopic approach for LS, this technique for DS also eliminates the incision between the two stomas and its complications. These authors describe that when taking down this DS, two transverse incisions can be done with good cosmetic results. However, in some cases an incision between the two ends is still required to be able to close the stoma securely. Taking the DS down, especially when done open but also in some laparoscopic cases, is a more complex operation that requires a laparotomy, with the disadvantages previously described. Also, although our results do not reach statistical significance, likely due to insufficient sample size, the higher tendency to wound complications after DS closure merits consideration and further study.\u003c/p\u003e \u003cp\u003eThe limitations of this study include its retrospective and observational nature with a limited number of patients. However, given the current literature and shift towards loop colostomies in some institutions, with reduced literature in the matter, we considered our results of interest.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eLaparoscopic LS in ARM patients is an easier procedure to perform and close, with a reduced surgical wound and the possibility to explore the pelvis. It does not have a higher risk of prolapse or UTI compared to the classic DS. Furthermore, DS had more postoperative complications, longer time to oral intake and stoma functioning and a more prolonged hospital stay.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cu\u003eFunding\u003c/u\u003e: The authors did not receive support from any organization for the submitted work.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eCompeting interests\u003c/u\u003e: The authors have no competing interests to declare that are relevant to the content of this article.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eEthics approval:\u003c/u\u003e All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by the Bioethics Committee of La Paz University Hospital (No. 2024.005).\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eConsent to participate and or publish\u003c/u\u003e: Written informed consent was obtained from the parents or legal guardians.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eData availability:\u003c/u\u003e The data that support the findings of this study are available from the corresponding author, upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePena A, Migotto-Krieger M, Levitt MA. Colostomy in anorectal malformations: A procedure with serious but preventable complications. J Pediatr Surg. 2006 Apr;41(4):748\u0026ndash;56. \u003c/li\u003e\n\u003cli\u003eYoussef F, Arbash G, Puligandla PS, Baird RJ. Loop versus divided colostomy for the management of anorectal malformations: a systematic review and meta-analysis. J Pediatr Surg. 2017 May;52(5):783\u0026ndash;90. \u003c/li\u003e\n\u003cli\u003eVan Den Hondel D, Sloots C, Meeussen C, Wijnen R. To split or not to split: Colostomy complications for anorectal malformations or hirschsprung disease: A single center experience and a systematic review of the literature. European Journal of Pediatric Surgery. 2014 Feb;24(1):61\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eKim W, Lee S, Seo JM. Vesicoureteral reflux increases the risk of urinary tract infection prior to corrective surgery in newborn males with anorectal malformation. Pediatr Surg Int. 2020 Dec 1;36(12):1495\u0026ndash;500. \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 Jan;49(1):87\u0026ndash;90. \u003c/li\u003e\n\u003cli\u003eLiechty ST, Barnhart DC, Huber JT, Zobell S, Rollins MD. The morbidity of a divided stoma compared to a loop colostomy in patients with anorectal malformation. J Pediatr Surg. 2016 Jan;51(1):107\u0026ndash;10. \u003c/li\u003e\n\u003cli\u003eLiem NT, Quynh TA. Single trocar laparoscopic-assisted colostomy in newborns. Pediatr Surg Int. 2013 Jun;29(6):651\u0026ndash;3. \u003c/li\u003e\n\u003cli\u003eMullassery D, Iacona R, Cross K, Blackburn S, Kiely E, Eaton S, et al. Loop colostomies are safe in anorectal malformations. J Pediatr Surg. 2018 Nov;53(11):2170\u0026ndash;3. \u003c/li\u003e\n\u003cli\u003eGardikis S, Antypas S, Mamoulakis C, Demetriades D, Dolatzas T, Tsalkidis A, et al. Colostomy type in anorectal malformations: 10-years experience. Minerva Pediatr. 2004 Aug;56(4):425\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eLevitt MA, Pe\u0026ntilde;a A. Anorectal malformations. Vol. 2, Orphanet Journal of Rare Diseases. BioMed Central Ltd.; 2007. \u003c/li\u003e\n\u003cli\u003ePe\u0026ntilde;a A, Devries PA. Posterior sagittal anorectoplasty: Important technical considerations and new applications. J Pediatr Surg. 1982 Dec;17(6):796\u0026ndash;811. \u003c/li\u003e\n\u003cli\u003e\u0026Ccedil;iğdem MK, Onen A, Duran H, \u0026Ouml;zt\u0026uuml;rk H, Ot\u0026ccedil;u S. The mechanical complications of colostomy in infants and children: analysis of 473 cases of a single center. Pediatr Surg Int. 2006 Aug 13;22(8):671\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eSanchez S, Ricca R, Joyner B, Waldhausen JHT. Vesicoureteral reflux and febrile urinary tract infections in anorectal malformations: A retrospective review. J Pediatr Surg. 2014 Jan;49(1):91\u0026ndash;4. \u003c/li\u003e\n\u003cli\u003eLiechty ST, Barnhart DC, Huber JT, Zobell S, Rollins MD. The morbidity of a divided stoma compared to a loop colostomy in patients with anorectal malformation. J Pediatr Surg. 2016 Jan;51(1):107\u0026ndash;10. \u003c/li\u003e\n\u003cli\u003eAnderson SA, Beierle EA, Chen MK. Role of laparoscopy in the prevention and in the treatment of adhesions. Semin Pediatr Surg. 2014 Dec 1;23(6):353\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eChoudhry MS, Grant HW. Small bowel obstruction due to adhesions following neonatal laparotomy. Pediatr Surg Int. 2006 Sep 14;22(9):729\u0026ndash;32. \u003c/li\u003e\n\u003cli\u003eGine C, Santiago S, Lara A, La\u0026iacute;n A, Lane V, Wood R, et al. Two-Port Laparoscopic Descending Colostomy with Separated Stomas for Anorectal Malformations in Newborns. European Journal of Pediatric Surgery. 2015 Nov 3;26(05):462\u0026ndash;4. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"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":"","lastPublishedDoi":"10.21203/rs.3.rs-4730029/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4730029/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eDivided sigmoidostomy (DS) is the classic stoma for patients with anorectal malformations (ARM). Loop sigmoidostomies (LS) in ARM are associated with higher risk of stoma prolapse and urinary tract infections (UTI). This is not clearly supported by literature. We compared our experience with both techniques.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eRetrospective study of ARM patients who underwent DS or LS between 2013\u0026ndash;2023. We analysed demographics, associated malformations, intraoperative variables, oral intake and stoma functioning times, hospital stay, complications, prolapses, and UTI.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOf 40 patients, 29 underwent open DS and 11 laparoscopic LS. Demographics, malformation type, associated anomalies, surgical time, intraoperative and anaesthetic complications were comparable. Postoperative complications were higher in DS than LS [14(48.3%) vs 1(9.1%), (p\u0026thinsp;=\u0026thinsp;0.02)], mostly due to wound complications [12(41.3%) vs 0(0%), (p\u0026thinsp;=\u0026thinsp;0.01)]; with 3 dehiscenses and 3 strictures reintervened. The hours to oral intake and stoma functioning were higher for DS [48(39\u0026ndash;90) and 48(24\u0026ndash;48) vs 24(24\u0026ndash;48) and 24(24\u0026ndash;24), (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05)], with more days of hospital stay [36(19\u0026ndash;60) vs 8(\u003cspan additionalcitationids=\"CR6 CR7 CR8 CR9\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), (p\u0026thinsp;=\u0026thinsp;0.001)]. Prolapses [1(3.4%) vs 1(9.1%)] and UTIs [3(10.3%) vs 1(9.1%) (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05)] were comparable.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eLS in ARM patients have no higher risk of prolapse or UTI than DS. DS had more complications, mostly wound infections, strictures and dehiscenses.\u003c/p\u003e","manuscriptTitle":"Classic Divided Sigmoidostomy Vs Loop Sigmoidostomy in Anorectal Malformations: Time for Change?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-11 12:14:41","doi":"10.21203/rs.3.rs-4730029/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-07-21T20:25:38+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-20T21:52:03+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-16T23:42:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"14677358015084010489786475496285119801","date":"2024-07-16T15:20:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"212785830631823755762364055535379928264","date":"2024-07-16T00:49:35+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-14T15:05:59+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-14T10:26:10+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-13T09:04:52+00:00","index":"","fulltext":""},{"type":"submitted","content":"Pediatric Surgery International","date":"2024-07-12T11:45:13+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":"6e3a92f7-cf79-4f71-9a17-63f5567c60d8","owner":[],"postedDate":"August 11th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-09-16T16:02:55+00:00","versionOfRecord":{"articleIdentity":"rs-4730029","link":"https://doi.org/10.1007/s00383-024-05834-6","journal":{"identity":"pediatric-surgery-international","isVorOnly":false,"title":"Pediatric Surgery International"},"publishedOn":"2024-09-10 15:57:43","publishedOnDateReadable":"September 10th, 2024"},"versionCreatedAt":"2024-08-11 12:14:41","video":"","vorDoi":"10.1007/s00383-024-05834-6","vorDoiUrl":"https://doi.org/10.1007/s00383-024-05834-6","workflowStages":[]},"version":"v1","identity":"rs-4730029","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4730029","identity":"rs-4730029","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}