Abdomino Posterio Saggital Anorectoplasty /Abdominoperineal Pull Through

Abdomino Posterior Sagittal Anorectoplasty in India

Abdomino-Posterior Sagittal Anorectoplasty (APSA) (also referred to as Abdomino-PSARP) is a complicated reconstructive surgical model utilized to mainly treat high anorectal malformations (ARM) and primarily in children.

Overview

• Anorectal malformations are birth defects in which the rectum and anus failed to develop, or are abnormally related to the urinary or genital tract.

The APSA represents a combination of two surgical procedures:

• Abdominal examination- to move and locate the rectum and fistula.
• Posterior sagittal positioning- to make a new anal opening and place the rectum in its proper position using the sphincter muscles.

Indications

APSA is indicated for:

• Anorectal malformations (high or complex e.g. recto-bladder neck fistula, recto-prostatic urethral fistula).
• Reoperative repairs of failed past repairs.
• Related anomalies necessitating abdominal opening (e.g. urogenital or spinal anomaly).

Surgical Procedure

• Anaesthesia and Positioning: Under general anaesthesia the patient is put in prone or lithotomy.

Abdominal Phase:

• Laparotomy/ laparoscopy is done.
• The rectum and any fistulous attachment to the urinary tract is determined and cleaved.
• The rectal pouch is brought downwards.

Posterior Sagittal Phase:

• It is cut along a midline starting at the sacrum to the perineum.
• The complex of the sphincter muscle is recognized.
• At the centre of the muscle complex a neoanus is formed.

Reconstruction:

• The rectumm mobilized is brought through the new anal canal.
• The rectum is sewn up to the perineal skin.

Postoperative Care

• In case of previous colostomy closure, it is not resurfaced until after the healing.
• Program with anal dilatement begins after 2-3 weeks to avoid stenosis.
• During recovery, bowel training and dietary management ensues.

Recovery and Outcomes

• Hospital stay: 7–10 days (may vary).
• The presence of a long period of bowel control is subject to the malformation and development of the sphincter muscles.
• With the good management of the bowel, most children become good in their continence.

PSARP surgery in India

Posterior Sagittal Anorectoplasty (PSARP) is a final surgical procedure applied to treat anorectal malformations (ARM) - a congenital defect whereby the rectum and anus is abnormally structured or related to the urinary or genital tract.
It is the gold standard of repairing most forms of anorectal malformations in infants and children that is developed by Dr. Alberto Peana in 1982.

Indications

PSARP is performed for:

• Newborn or infant high, intermediate or low anorectal malformations.
• Recto-urethral/recto-vaginal fistula.
• Imperforate anus (no anal opening)
• Reoperative surgery of anorectal repair.

Surgical Steps

Preoperative Preparation:

• A diverting colostomy is typically performed shortly after birth in order to guard the intestines against infection.
• PSARP is later done (typically at 3-6 months of age).

Anaesthesia and Positioning:

• The child is put in the jackknife position in the prone position as a result of general anaesthesia.

Posterior Sagittal Approach:

• The incision is made in the middle between the sacrum and the perineum.
• A complex of sphincter muscle is detected with the help of an electrical stimulator.
• The rectal region is identified and distinctly dispassionately divided against the urinary or genital organs.

Rectal Pull-Through:

• The rectum is moved about and brought down in the midst of the sphincter muscles.
• The neoanus (new anal opening) is made at the right anatomical location.
• The rectum is stitched to the perineal skin.

Colostomy Closure:

• Six-eight weeks or so after healing, the colostomy is reversed and the normal passage of the bowel is regained.

Postoperative Care

• To avoid narrowing, anal dilatation starts 2-3 weeks after surgery.
• Bowel management program is persisted as a means to attain continence.
• Habitual consultations with pediatric surgeons and gastroenterologists.

Recovery and Outcome

• Hospital stay: around 5–7 days.
• Complete recovery might require a couple of months.
• Most children are able to achieve good bowel control and lead a normal life with proper aftercare.

Key Advantages of PSARP

• Gives direct visualization of the structures in the pelvis.
• Enables accurate positioning of the rectum by the sphincter muscle complex.
• Improved long-term functional outcomes than older blind perineal repairs.

Best hospitals for anorectal malformation surgery in India

• Artemis Hospital, Gurgaon
• Medanta-The Medicity, Gurgaon
• Fortis Memorial Research Institute, Gurgaon
• Max Hospital, Saket

Factors Affecting Pediatric anorectal surgery cost in India

The determinants of the cost of pediatric anorectal (PSARP / staged ARM) surgery in India:

Morphology and multifactoriality of the malformation

• High or complex ARMs (recto-urethral, recto-bladder neck fistula, related spinal/urogenital anomalies) will typically take longer to operate, abdominal component (laparotomy/laparoscopy) or multi-stage care - again increasing the cost. 

Number of stages (single-stage vs staged repair)

• Three stages (colostomy, PSARP, colostomy repair) are very costly compared to one-stage surgeries since they need numerous admissions, procedures, anaesthesia and follow up procedures. Single stage neonatal PSARP is available in some centres and may help to decrease the overall cost of the case. 

Hospital type & location

• The big metro cities have large numbers of tertiary hospitals owned privately which are very expensive as compared to the government tertiary hospitals or the small privately owned hospitals. There is also the issue of city-to-city difference (Delhi/Mumbai/Bengaluru vs smaller cities). 

Surgeon & anaesthesiologist charges

• Well known pediatric colorectal surgeons and anaesthetists have higher professional fee charges - this is an item on the bill that is discrete. 

Operating theatre time, equipment & consumables

• Longer OT time, laparoscopy, specialised equipment, sutures, staplers or disposable equipment are all costly. Where there are any prosthetic or specialised anal dilator sets, they are included in consumables. 

ICU/NICU stay and bed category

• In case the child requires ICU or NICU follow-up treatment after operation, nursing charges (which may be substantial in non-state hospitals) on a daily basis become a significant factor of cost. The category of bed (shared or single private room) also influences the bill. 

Pre-operative studies and radiography

• Additional cost to preoperative cost includes high-resolution imaging, spinal MRI (when there is a suspected tethering), thorough urological (VCUG) tests, labs and anaesthesia fitness tests. 

Hospital stay and complications

• The total cost is higher in case of longer inpatient hospital stays because of wound problems, infections, re-injuries or bowel programs. Frequent fistula repair or dilation of stenosis are also extra expenses. 

Post-op treatment, rehabilitation and follow-up

• Recurring costs are anal dilatation sets, bowel management supplies, frequent outpatient visits, physiotherapy (when necessary), and long-term continence programs.

Anorectal malformation treatment in India

Anorectal malformation (ARM) is a malformation that occurs during the early development of the rectum and anus. Under such circumstances, the anal orifice may be absent, displaced or abnormally attached to the urinary or genital tract by a fistula.
It presents with a frequency of approximately 1 per 4,000-5,000 live births and is surgically remediable in order to enable normal faecal passage.

Goals of Treatment

• Make an effective anal aperture at the right place.
• Conserve the sphincter muscles and nerves to have continence.
• Fix any related fistula of the rectum and urinary/reproductive system.
• Bowel control and hygiene after surgery.

Categories of Anorectal Malformations

• Low-type ARM: The rectum terminates very near the perineum (easy to repair).
• Intermediate type ARM: A higher rectal end which may contain a small fistula.
• High-type ARM: Rectum joins to urinary tract (in boys) or vagina (in girls); complicated and needs to be repaired in stages.

Treatment Stages

Primary Evaluation and Resuscitation

• Performed soon after birth.
• Physicians test related abnormalities (cardiac, renal, spinal).
• A temporary colostomy is usually made in cases where the stool is diverted to avoid infections in most complicated cases.

Definitive Surgery

• The kind of surgery is based on the degree and level of the malformation.

Posterior Sagittal Anorectoplasty (PSARP / Peña Procedure):

• Majority of corrective surgery.
• The surgeon incises an area midline between the sacrum and the perineum.
• The rectum is displaced and displaced down through the middle of the sphincter muscle complex.
• The appropriate position of a new anal opening (neoanus) develops.
• Typically done 3-6 months following colostomy.

Abdominal-Posterior Sagittal Anorectoplasty (APSA):

• Applied on high or complex malformations, where there is a fistula of the recto-bladder neck.
• Also uses abdominal and posterior sagittal to have full visualization.

Primary Neonatal Repair:

• In a few low-type ARMs, a surgical procedure can occur shortly after birth without colostomy.
• The rectum is introduced to the perineum (single-stage repair).

Laparoscopic-Assisted Anorectoplasty (LAARP):

• Minimally invasive laparoscopic approach.
• Enhances accurate rectal mobilisation and less post-operative pain.

Colostomy Closure

• Carried out some 6-8 weeks following definite repair after the neoanus has healed.
• Reinstates normal bowel continuity.

Postoperative Care

• Anal dilatation: Begins 2-3 weeks after surgery in order to avoid constriction.
• Bowel management: Involves diet, laxatives and toilet training to maintain continence.
• Physiotherapy and constant follow up to check bowel control and muscle tone.

Recovery and Long-Term Outlook

• Hospital stay: 5–10 days.
• The process can take several months to be fully recovered.
• As a result of proper follow-up, bowel management, and physiotherapy, most children acquire bowel control.
• Constant surveillance through adolescence is significant in the aspect of continence, growth, and quality of life.

Factors Affecting Abdomino posterior sagittal anorectoplasty cost in India

The determinants of cost of Abdomino-Posterior Sagittal Anorectoplasty (APSA) in India:

Type and degree of Malformation

• Higher ARM, long fistula, or other related genitourinary or spinal malformations (more complex anorectal malformation) imply increased surgical time, increased dissection, maybe combined abdominal + posterior surgical approach. Surgeons and more resources engaged.

Preoperative Evaluations

• Comprehensive imaging (MRI, ultrasound), endoscopic/urodynamic examinations, anaesthetic examination, renal scans. These are required particularly in the case where there are related defects (e.g. spinal tethered cord, kidney problems).

Staged vs. Single-Stage Repair

• Assuming that an operation is possible, multiple operations (one with their OT, anaesthesia and hospital stay) are required if a colostomy is performed initially and reversed later, compared to one operation. APSA itself is more participatory than PSARP per se, and staging contributes to overall expense.

Operation Theatre Time and Techniques

• OT time is added in the abdominal part. Cost increases in case laparoscopic or minimal abdominal access is used, or special equipment / devices / retractors are necessary. Consumables are added with the use of surgical staplers, use of advanced surgical instruments, use of special sutures etc.

Surgeon & Team Expertise

• Experienced colorectal paediatrics receives higher rates. The older or more specialized the team (e.g. with pediatric urologists, radiologists, anaesthesiologists), the greater the professional fees.

Type of Hospital and infrastructure

• Advanced neonatal/pediatric surgery ICUs, neonatal anaesthetists, NICU/ICU backup, well-equipped OT etc. are found in the private tertiary care hospitals, costing more than the government or smaller centres.

Bed/Room Type & Amenities

• The cost of the private/ private deluxe rooms is higher; the ward/shared rooms are lower. The additional facilities (personal nursing, additional comforts) are expensive.

Length of Stay & Post-Op Care

• AP-PSA probably requires a protracted admittance (OT recovery, ICU/NICU (as necessary) wound follow-up, perhaps complication oversight. In case of prolonged post-op stay (because of infection, wound problems) the costs are high.

ICU/NICU Costs

• ICU charges per day are high in case of child requiring neonatal ICU and pediatric ICU during and after surgery (in infants in particular). Ventilation, monitoring etc accumulate.

Consumables & Implants

• Adds sutures, staplers, drains, catheters, stoma supplies (colostomy), analgesia devices, dilators, dressing. The cost of imports, tax, markups are important.

Perioperative Care Anaesthesia

• The costs of anaesthesia depend on time, complication (presence of an abdominal stage and another perineal, the use of peripheral / epidural adjuncts). And after-surgery pain treatment.

Pre and Post Surgery follow up and Bowel Management

• Dilatation programs, follow-up clinic, potential physiotherapy, treatment of continuence/constipation using medication/diet. These are recurring costs.

Related Inconsistencies / Co-morbidities

• A high number of ARMs are associated with urological, spinal, cardiac anomalies. When they have to be considered or treated at the same time, the price increases. As an example, fistula urethra repair, this requires urology or reconstruction, or cardiac clearance, or cardiac surgery.

Complications

• Issues such as wound dehiscence, infection, stenosis, re-operation or revision are all additional expenses. Longer hospital days, longer number of meds, longer number of OT time.

Geographical Location / City

• Large big metro cities (Delhi, Mumbai, Bangalore, Chennai etc) are more expensive in labour and rent and staff charges, which are reflected in the bills. Smaller towns or cities are cheaper.

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